Orthopädie Bonn, Dr. Kurt Schöppe: questionnaire: lumbar spine

Praxisklinik für Orthopädie
Dr. med. Kurt Schöppe - Prof. Dr. K.-P. Schulitz
Orthopädie-Schmerztherapie-Chirugie
Rochusstraße 289 - 53123 Bonn-Duisdorf
Tel.: 0228 3863060

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Medical history questionnaire: lumbar spine

Address:
First name:
Last name:
Birthday:
(DD.MM.YYYY)
Telephone:
Street:
City:
ZIP-Code:
Country:
Insured with:
1. Where is the pain located? Please describe it
2. Do you have radiating pain?
3. Since when do you have back pain?

4. I have pain in the leg
4. I have pain in the legleft
right

5. I have pain in the back
5. I have pain in the backleft
right
centered

6. I have mainly:
6. I have mainly:more pain in the leg
more back pain
equally bad

7. I have pain in the buttocks
7. I have pain in the buttocksleft
right

8. Coughing and sneezing aggravates the pain
8. Coughing and sneezing aggravates the painnot true
slightly
strongly

9. I have pain when laying down
9. I have pain when laying downnot true
slightly
strongly

10. I have pain while walking
10. I have pain while walkingnot true
slightly
strongly

11. I have pain while sitting
11. I have pain while sittingnot true
slightly
strongly

12. I have pain while standing
12. I have pain while standingnot true
slightly
strongly

13. I have pain while
13. I have pain whilestretching
bending down
lifting

14. When do you have the most pain?
14. When do you have the most pain?sitting
standing
walking
laying down

15. What caused the pain? (accident, heavy lifting i.e.)

16. Did the pain start slowly, without any cause?
16. Did the pain start slowly, without any cause?yes
no

17. Do you have less power in the legs?
17. Do you have less power in the legs?yes
no

18. Do you have less feeling in the legs?
18. Do you have less feeling in the legs?yes
no

19. Were you already operated at the spine? If yes, which operations were was performed?
20. Which treatments were performed for your back and leg pain and which were the results?

21. Are you allergic against certain drugs?
21. Are you allergic against certain drugs?yes
no
which?

22. Do you take hormones or the pill?
22. Do you take hormones or the pill?yes
no

23. Did you ever have a thrombosis?
23. Did you ever have a thrombosis?yes
no

24. Did you do sports before?
24. Did you do sports before?yes
no
which sport?

25. How often per month?

26a. Include your MRT report here (not older than 3 months)
26b. I sent my MRT report via fax(not older than 3 months)
26c. I sent my MRT report vial mail (not older than 3 months) on: