Name:
First name:
Birth date:	( TT.MM.JJJJ )
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City and postal code:
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1. Where is the local and possibly referred pain located? (Please click)
2. Since when you have leg / back pain:
3. I have back pain	yes no
4. I have leg pain	left right no
5. I have pain in the buttocks	left right no
6. I have mostly	Back pain Leg pain equally bad
7. When I sneeze or cough the pain increases	no hardly clearly
8. When I lie I have pain	no hardly clearly
9. When I walk I have pain	no hardly clearly
10. When I sit I have pain	no hardly clearly
11. When I stand I have pain	no hardly clearly
12. What hurts most? sitting standing walking lying	sitting standing walking lying
13. Was there a cause for your back/leg problems (e.g. accident, heavy lifting)?
14. Is there a loss of strength in your leg?	yes no
15. Is there a loss of sensation in your leg?	yes no
16. Have you been operated on your back before?	yes no
17. If so, what was done and when?
18. What kind(s) of treatment have you had so far and what was the result?
19. Do you want a cost estimate?	yes no
20. 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)