What would you like us to call you? *
What is your age? *
What is your sex? *
M aleF emale
Email Address *
Contact Number *
What kind of work do you do? *
Have you had any previous spinal surgery? *
Y esN o
If yes, when and what is your understanding of what was done?
Do you believe the operation to have been successful?
Y esN o
Do you still have symptoms following the surgery?
Y esN o
Did you have relief of your symptoms, but found that the old symptoms have reappeared?
Y esN o
Did you have relief of your symptoms, but found that you have developed new symptoms?
Y esN o
Are you generally healthy?
Y esN o
If not, please list your conditions
Do you smoke?
Y es
Do you have any history of cancer or growths that needed removal?
Y esN o
If yes, please list
Do you have any chronic infective disease?
Y esN o
If yes, please list
Do you believe that you have an acute infective disease?
Y esN o
If yes, please list
Have you been involved in an accident or a fall in the last five years?
Y esN o
If yes, please clarify?
How long have you had back pain?
1 - 2 weeks2 - 4 weeks1 - 3 months3 - 6 months6 - 12 months1 - 2 yearsm ore than 2 years
Has it steadily gotten worse?
Y esN o
Has it suddenly gotten worse?
Y esN o
Over what period has it gotten worse?
1 - 2 weeks2 - 4 weeks1 - 3 months3 - 6 monthsm ore than 6 months
Which part of your back is painful?
I n the middleo n the lefto n the right
Does coughing or sneezing or straining when you are sitting on the toilet aggravate the pain?
Y esN o
What causes pain?
What causes the most pain?
S ittingS tandingW alkingL ying down
Do you find that your pain becomes worse on walking and gets better when you rest?
Y esN o
Do you find that your leg(s) feel weak or give away under you?
Y esN o
Do you find that getting up from a chair is difficult?
Y esN o
Do you have difficulties getting out of bed?
Y esN o
Do you find that as soon as you get going that the pain eases?
Y esN o
Can you do most activities and even sport relatively pain free, but suffer as soon as you stop or the next day?
Y esN o
Does your pain spread to other areas of your body?
Do you have a feeling of pins and needles that extends down your leg to beyond your knee?
Y esN o
If yes, which leg?
R ight legL eft leg
Does it extend to your:
For men - Have you suddenly noticed the loss of erections?
For men and women - Do you have new difficulties in passing water or passing stools or suffer from sudden incontinence?
For men and women - Have you noticed a sudden numbness in your genitals or around your anus?
How long have you had neck pain?
1 - 2 weeks2 - 4 weeks1 - 3 months3 - 6 months6 - 12 months1 - 2 yearsm ore than 2 years
Has it steadily gotten worse?
Y esN o
Has it suddenly gotten worse?
Y esN o
Over what period has it gotten worse?
1 - 2 weeks2 - 4 weeks1 - 3 months3 - 6 monthsm ore than 6 months
Which part of your neck is painful?
I n the middleo n the lefto n the right
Does your pain spread to other areas of your body?
Does moving your neck increase the pain?
Y esN o
Do you have a feeling of pins and needles that extends down your arm?
Y esN o
If yes, which arm?
R ightL eft
Tests that have been performed on you.
X-ray
MRI scan
CT scan
Myelogram
EMG
Radio Isotope scan
Bone Density scan
