Name:
First name:
Birth date:	( TT.MM.JJJJ )
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1. Where is the local and possibly referred pain located? (Please click)
2. Since when you have neck / arm pain:
3. What makes the pain worse?
4. What reduces the pain?
5. I have mostly	Neck pain Arm pain equally bad
6. I have pain in the arm	left right no
7. Do you have pain at night?	often rarely no
8. Does the pain increase when you turn your head	left right no
9. The pain increases when	I bend forward I bend backward
10. Do you have headaches?	often rarely no
11. What kind(s) of treatment have you had so far and what was the result?
12. Do you want a cost estimate?	yes no
13. What is the result/conclusion of the last MRI, MRT or CT (you can send also by fax to +45 98173244) Without this information, no diagnosis can be made!
File upload (pics or report)