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 neck, shoulder pain or radiating pain to head, shoulder, arm, finger
  - CERVICAL -  

 

    Neck pain (dull pain, fatigue, tiredness, compressed sensation)?
              Check left, right or both.
              Check intermittent(sometimes) or continuous(anytime).

     

      left      right    both sides  / intermittent     anytime

    Shoulder pain (dull pain, fatigue, tiredness or compressed sensation)?

     

      left      right    both shoulder / intermittent    continuous

    Shoulder pain (numbness, pricking or tingling sensation)?

     

      left      right    both Shoulder / intermittent    continuous

    Arm pain (numbness, pricking or tingling sensation)?

     

      left      right    both sides / intermittent     continuous

    Thumb pain (numbness, pricking or tingling sensation)?

     

      left      right    both sides  / intermittent     continuous

    The 2,3rd finger pain (numbness, pricking or tingling sensation)?

     

      left      right    both sides / intermittent continuous

    The 4,5th finger pain (numbness, pricking or tingling sensation)?

     

      left      right    both sides / intermittent   continuous


    Numbness? Where, Lesion?

    Weakness? Where or Motion?
     

    Is pain aggravated with postural change (head-up, down, left, right)?

        upward      downward    same(up-down)    left     right

    When you bend your waist laterally-lesion side, pain is more aggravated?

    When you bend your waist laterally-opposite side of lesion, pain is more aggravated?

    When you bend your waist laterally-both left or right, No difference?

    Is pain subsided on laying down?

      no pain on laying down     decrease    no change, continuous   


    1st onset of symptom (example, 1998.12.24.)

     Recent 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 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 cervical operation history? /  Dr. drived to get surgery but you refused?

     when (1999. 04. 21.)

      Hospital,   Dr.

     Operation title ,   Scar cm


    Any dental problem?

    Dizzy frequently?

    Severe rhumatoid arthritis?

    Any syncope or unconsciousness history?

    Epilepsy?

    Dermatologic disease?

    Ruptured cervical ligament?


    neck circumference   cm or inch

                         Height   cm, or inch, feet

                         Weight   Kg, or lb