Questionnaire for the intervertebral disc prosthesis | Yes, Have, Pain, Little, Clearly

...finally move pain-free again!

Questionnaire for the intervertebral disc prosthesis

Do you have discomfort?

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first name *
family name *
date of birth *

phone *
email *
mobile
fax

street
zip/city
country

treatment costs are covered by:
insurance name
I get aid (support):	no yes
* input required

Since when have you had the current complaints?

Back pain?	left right no
Leg pain?	left right no
Pain in my buttocks?	left right no
When I sneeze or cough the pain increases cough/sneeze	no a little clearly

Do you have complaints…
…while lying?	no a little clearly
…while walking?	no a little clearly
…while sitting?	no a little clearly
…while standing?	no a little clearly
What hurts most?	lying walking sitting standing

Durch welchen Anlass sind die Beschwerden eingetreten? (z.B. Unfall, schweres Heben, etc.)

Do you have loss of strength in your leg?	no yes
Do you have loss of sensation in your leg?	no yes

Have you been operated on your back before?	no yes
what kind of operation was that and

What kind(s) of treatment have you had so far and what was the result?

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