WIRBELSÄULENCHIRURGIE Anamnesis Lumbar Spine Motion ... FÜR FUNKTIONSERHALTENDE WIRBELSÄULENCHIRURGIE page 1
WIRBELSÄULENCHIRURGIE Anamnesis Lumbar Spine Motion ... FÜR FUNKTIONSERHALTENDE WIRBELSÄULENCHIRURGIE page 2
WIRBELSÄULENCHIRURGIE Anamnesis Lumbar Spine Motion ... FÜR FUNKTIONSERHALTENDE WIRBELSÄULENCHIRURGIE page 3

WIRBELSÄULENCHIRURGIE Anamnesis Lumbar Spine Motion ... FÜR FUNKTIONSERHALTENDE WIRBELSÄULENCHIRURGIE

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  • ZENTRUM FR FUNKTIONSERHALTENDE WIRBELSULENCHIRURGIE

    Orthopdie und Neurochirurgie Dr. Michael SchubertDr. Armin Helmbrecht

    APEX SPINE CENTERHelene-Weber-Allee 1980637 Mnchen

    Telefon/Fax: +49 (0)700 20 4000 20 Web: www.apex-spine.comE-Mail: info@apex-spine.com

    Motion preservation spinesurgery

    surname

    city

    fax

    e-mail

    general informations

    first name

    date of birth

    adress

    country

    contact informations

    phone

    mobile

    your pain areas

    Where in your body is the pain located?

    Anamnesis Lumbar SpinePage 1 of 3

    Fax: ++49 (0)700 20 4000 20

  • ZENTRUM FR FUNKTIONSERHALTENDE WIRBELSULENCHIRURGIE

    Orthopdie und Neurochirurgie Dr. Michael SchubertDr. Armin Helmbrecht

    APEX SPINE CENTERHelene-Weber-Allee 1980637 Mnchen

    Telefon/Fax: +49 (0)700 20 4000 20 Web: www.apex-spine.comE-Mail: info@apex-spine.com

    Motion preservation spinesurgery

    Your health complaints

    Since when hve you had the current complaints

    I have back pain yes no

    I have leg pain left right no

    I have pain in my fundament ileft right no

    When I sneeze or cough the pain increases no little yes

    When I lie I have pain no little yes

    When I walk I have pain no little yes

    When I sit I habe pain no little yes

    When I stand I have pain no little yes

    What hurts most sitting standing

    going lying

    Was there a cause for your back/leg problems (e.g. accident, heavy lifting)

    Is there a loss of strength in your leg yes no

    s there a loss of sensation in your leg yes no

    Have you operated on your back yes no

    If so, what kind of operation was that and when did it take place

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

    Anamnesis Lumbar SpinePage 2 of 3

    Fax: +49 (0)700 20 4000 20

  • ZENTRUM FR FUNKTIONSERHALTENDE WIRBELSULENCHIRURGIE

    Orthopdie und Neurochirurgie Dr. Michael SchubertDr. Armin Helmbrecht

    APEX SPINE CENTERHelene-Weber-Allee 1980637 Mnchen

    Telefon/Fax: +49 (0)700 20 4000 20 Web: www.apex-spine.comE-Mail: info@apex-spine.com

    Motion preservation spinesurgery

    Your health complaints

    Did you do any sports before the complaints arose yes no

    If so, what kind of sport

    What is the result/conclusion of the last MRI, MRT or CT

    Anamnesis Lumbar SpinePage 2 of 3

    Fax: +49 (0)700 20 4000 20