This chart is for evaluation of your spine health condition. 
 If, don`t mind, describe everything and I`ll reply you, soon.

First Name

Family Name

Age

years old

Sex

Mrs.   Miss   Mr. / Dr.   DC.   DO.   PT.  

Race

Marriage

Married     Single

Occupation

Usual Posture on working

Blood type

A    B    AB O  /  Rh+    Rh-

Address

Address

City

State

Nation

Zip Code

Telephone

Fax.

e-mail

URL



Write numbers of lesion(pain)- Painful lesions are
                                                                      
(example, 2, 4, 5, 13, 14)


In low back pain or radiating pain to hip, leg, foot
  - LUMBAR -

 

     Low back pain?
              Check left, right or both.
              Check intermittent(sometimes) or continuous(anytime).

     

      left      right    both sides / intermittent     anytime

    hip pain, sciatica?

     

      left      right    both sides / intermittent     continuous

    Pulling or tingling sensation on thigh? front  side   back

     

      left      right    both sides / intermittent     continuous

    Tingling sensation or numbness on lateral(side) calf?

     

      left      right    both sides / intermittent     continuous

    Tingling sensation or numbness on posterior(back) calf?

     

      left      right    both sides / intermittent     continuous

    Tingling sensation or numbness on foot dorsum?

     

      left      right    both sides / intermittent     continuous

    Tingling sensation or numbness on heel?

     

      left      right    both sides / intermittent     continuous

    Claudication, tingling sensation or numbness on sole?

     

      left      right    both sides / intermittent     continuous
     

    Numbness? Where, Lesion?

    Weakness? Where or Motion?
     

      When you bend your waist forward or sitting down), pain is more aggravated?

      When you bend your waist backward or walking, more aggravated?

      No significant difference between sitting down and walking?

    Pain is aggravated on standing or walking only (claudication) and
           no symptom on sitting down with your waist forward bended?

    No pain on laying down?

    Decreased pain on laying down?

    Pain is continuous with postural change?


    1st onset of symptom (example, 1998.12.24.)

     

    Recent(reaggravated) onset of symptom (example, 1999.10.30.)


    Injury history? ->If you were injured, when / how?
                              (example, 1999.10.29. / after playing golf or lifting heavy material)

    No remember about injury history
     

    Have your symptom begun abruptly?

    Have your symptom begun insidiously, year by year?


    Have you ever been diagnosed in hospital or clinic?

      Hosp.        clinic  
           Dept.         
    Dr.

    Diagnosis

    Examination

    X-Ray?

    CT-Scan

    MRI

    Dr.`s treatment plan


    Physical therapy history?

    Traction treatment experience?

     

    During traction treatment on lying down

      

    No pain?

      

    Better?

     

    No releive from pain even during traction?

     

    Aggravated pain during traction treatment?

     

    Can not remember?

       Comfortable during traction, but recurred pain after that?

    Have you understood well about the principles of treatment and the importance of posture from Dr.?



    Any lumbar operation history?
    Dr. drived to perform surgery but you refused?

     when (1999. 04. 21.)

      Hospital Dept. Dr.

     Operation title ,   Scar cm

    Any cardiovascular disease? -Diagnosis & Symptom

    Dyspnea due to pulmonary disease?

    Severe rheumatoid arthritis?

    Any syncope history?

    Epilepsy?

    Pregnancy now?

    Any digestive disease?

    Any dermatologic problem?

    Any hematologic disease?

    Hypertension?

    controlling with drug?

    Severe osteoporosis?

    controlling now?

    Pathologic fracture history?

    Diabetes mellitus?

    Controlling now?

    Any adverse effect or anaphylaxis of drug?

    Additional comment :


    Waist size (Umbilicus) Cm,  or inch,  when
    relax.
    Waist size (Umbilicus) Cm,  or inch,  when
    suck in your stomack.

          Height   Cm, or inch/ feet

         Weight   Kg,  or lb