Medical history form for the cervical spine

first name *
family name *
date of birth *

phone *
email *
mobile
fax

street
zip/city
country

treatment costs are covered by: *
insurance name
I get aid (support):	Нет Да

* input required

Where in your body is the pain located?

Click to enable/disable a spot

Since when have you Neck- / Arm pain? *

What aggravates the pain?

What reduces the pain?

What hurts more?	Neck pain Arm pain back/leg pain about the same
armpain?	left right Нет
Are you having pain at night?	often sporadic Нет

* input required

Have you got headaches?	often sporadic Нет
The pain increases when I turn my head to	left right
The pain increase when I turn my head	forward backward

What kind(s) of treatment have you had so far and what was the result?

Result of the recent magnetic resonance imaging
(MRT) or Computertomography(CT)
Without this information, no diagnosis can be made!

You have the ability to upload up to 5 files (eg findings, radiographs, etc.)
supported file formats: JPG, PDF, GIF, PNG, DOC, DOCX, DICOM, ZIP

Do you wish a cost estimate?

Нет Да

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