Confidential Data of the Patient
Please take a minute to fill in the following information
First Name
Last Name
Gender
Female
Male
Other
Email
Phone Number
Address
Who is your medical doctor?
ID nr/Date of Birth
Who is responsible for this account?
SVB
Guardian
Sagicor
ENNIA
Own Account
Other
What is your main complaint?
60
Your Pain on a Scale of 1-10?
1) no pain
2) hardly notice pain
3) sometimes distracts me
4) distracts me, can do usual activities
5) interrupts some activities
6) hard to ignore, avoid usual activities
7) focus of attention, prevents doing daily activities
8) awful, hard to do anything
9) can't bear the pain, unable to do anything
10) as bad as it could be, nothing else matters
Have you already received a diagnosis for these symptoms?
60
What do you think is the cause of the complaint?
60
How long have you been suffering from this complaint?
60
What actions worsen you condition?
60
Medication you use?
Painkillers
Muscle relaxants
Tranquilizers
Birth control pills
Other
None
What is the name of medicine?
Does sneezing and coughing cause pain or radiation?
How many times a week do you have a bowel movement?
Do you suffer from a headache?
No, never
Sometimes
A lot
All the time
What type of headaches?
Cluster headaches
Migraine
New daily persistent headaches (NDPH)
Tension headaches
Headaches coming from the neck area
Other
What kind of mattress?
Ortho
Semi-ortho
Other
Have you ever been in a car accident?
Past Year
Past 5 Years
More than 5 years ago
Never
Have you ever had a fracture or contusion?
60
Have you ever been treated for spine- or nerve problems?
60
Do you use vitamins and/or minerals?
60
Are you allergic to:
Medication
Foods
Other
None
Do you have other symptoms that are important, such as:
Cardiovascular
Breathing
Genitals/urine
Stomach/intestines
Nervous system
Other
None
Alcohol
Much
Moderate
Little
None
Coffee
Much
Moderate
Little
None
Drugs
Much
Moderate
Little
None
Physical exercise
Much
Moderate
Little
None
Smoking
Much
Moderate
Little
None
Which of these examinations you had in the last 2 years?
Medical examination
Blood/urine examination
X-Rays
MRI/CT-scan
EMG test
X-Rays
Date of examination
Enter text here
What time of day do you experience the most pain?
How do you sleep?
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ID/SVB
Your Signature
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