Medical history questionnaire: cervical spine

Address: Mr.Mrs.Ms.

First name:

Last name:

Birthday:
(DD.MM.YYYY)

Telephone:

Street:

City:

ZIP-Code:

Country:

Insured with:

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1. Where is the pain located? Please describe it

2. Do you have radiating pain?

3. Do you have somewhere a deaf feeling?

4. Since when do you have pain?

5. What aggravates the pain?

6. With what do you relief the pain?

7. The pain increases while turning the head

7. The pain increases while turning the head

to the left
to the right

8. The pain increases

8. The pain increases

when bending the head down in front
when bending the head towards the back

9. Do you suffer from headache?

9. Do you suffer from headache?

often
rarely
not at all

10. Which treatment was performed to relieve the disturbances of your cervical spine and which were the results

11a. Include your MRT report (not older than 3 months)

11b. I sent my MRT report via fax(not older than 3 months)

11c. I sent my MRT report vial postal mail (not older than 3 months) on: