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
City
State
Nation
Zip Code
Telephone
Fax.
e-mail
URL
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)?
The 2,3rd finger pain (numbness, pricking or tingling sensation)?
The 4,5th finger pain (numbness, pricking or tingling sensation)?
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?
¢º Hosp. clinic Dept. Dr.
¢º Diagnosis
¢º Examination
X-Ray?
CT-Scan?
MRI?
¢º 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?
¢º when (1999. 04. 21.)
¢º Hospital, Dr.
¢º 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