Medical Concierge Service in Excellence

MEDICAL HISTORY FORM WITH NECK/BACK and/or ARM/LEG PROBLEMS

1. Where in your body is the pain located?
(Please choose from the following options, multiple choice is available.)

Body Part *
Neck location
Back location
Arm location
Leg location
Don't find the right location, you can write down, in own words, where you locate the pain.
4. I have
5. When I sneeze or cough the pain increases
6. When I lie I have pain
7. When I walk I have pain
8. When I sit I have pain
9. When I stand I have pain
10. I have pain when I
11. What hurts most?
13. Have your complaints come about without cause?
14 a. Is there a loss of strength in your leg?
14 b. Is there a loss of strength in your arm/hand?
15 a. Is there a loss of sensation in your leg?
15 B. Is there a loss of sensation in your neck/back?
18. Are you allergic to any kind of drugs?
19. Do you take hormones or anticonceptive medication?
20. Have you ever had thrombosis?
21. Did you do any sports before the complaints arose?

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