EmailMeForm
ThePain.net low back pain symptoms/complaints form
When you're going to the doctor´s appointment, you can fill out this form and send it to your own email. From there you can print it out as a reminder for your visit, or if your doctor accepts e-mail, forward it to her/him before the reception. You can also print a blank form and fill it by hand. This may help you to remember better the essential information. Your doctor may get a clearer picture and more time to examine and think about your problems. The form or any other material on this site is not intended to substitute professional medical advice, diagnosis, or treatment.
The sections marked with the star must be filled so that the form can be sent.
My low back pain began
*
Write here the time you had first low back pain.
My low back pain began
little by little.
suddenly.
I have had
a trauma of my low back.
no trauma of my low back.
The type and date of the trauma:
Write here the date of the trauma of your low back and describe its character. If none, leave it empty.
My low back pain got worse
Write here the last time you low back pain got worse. If none, leave it empty.
My pain can be characterized as
Write here the character of your low back pain. For instance sharp, dull, burning, throbbing etc.
Pain intensity on a scale of 0-10 is
Write here your estimate of the intensity of your low back pain on a scale o 0-10. (0=no pain - 10=worse pain ever)
This is my
*
first episode of low back pain.
second episode of low back pain.
third or more than third episode of low back pain.
Previous episodes of my low back pain lasted for
Write here the duration of the previous episodes of your low back pain. If none, leave it empty.
Low back pain started this time
in connection with heavy lifting or other hard work.
in connection with a direct blow or a low back trauma.
in connection with a sudden movement or a sports performance.
in connection with long standing.
in connection with long sitting.
in connection with sleeping.
for no particular reason.
in some other situation.
Choose the best option or write it in the free space.
In relation to the middle line of the low back, the pain is felt
in the middle.
on the right side.
on the left side.
along the entire width of the low back area.
elsewhere:
Choose the best option or write it in the free space.
Pain is felt in an up-down direction
on the level of the shoulder blades.
on the level of the navel.
on the level of the lower back.
on the level of the buttocks.
on another level:
Choose the best option or write it in the free space.
My low back pain gets worse when
Write here what makes your low back pain worse.
My low back pain gets better when
Write here what makes your low back pain better.
My low back pain is felt
all the time.
most of the day.
only part of the day.
not every day, a few times a week.
approximately once a week.
approximately once every two weeks.
approximately once a month.
less frequently than once a month.
Choose the best option.
My low back pain
*
wakes me up every night.
wakes me up sometimes.
does not wakes me up.
Choose the best option.
My low back
*
has been operated.
has not been operated.
The low back surgery was
If your low back was operated, write here the time of the surgery and its type.
I have
*
fecal incontinence problems.
urinary incontinence problems.
weakness or paralysis of the right leg.
weakness or paralysis of the left leg.
weakness or paralysis of the right and left leg.
no leg weakness or paralysis.
My low back pain also
*
radiates to the leg.
does not radiate to the leg.
The worst radiation is
to the the right thigh.
below the knee on the right.
to the toes on the right.
to the left thigh.
below the knee on the left.
to the toes on the left.
elsewhere:
If you had radiating pain write it here. Choose the best option or write it in the free space.
I have numbness or tingling
on the the right thigh.
below the knee on the right.
on the toes on the right.
on the left thigh.
below the knee on the left.
on the toes on the left.
elsewhere:
If you have numbness or tingling write it here. Choose the best option or write it in the free space.
I have pains also in other areas, such as
Write here if you have pains in other areas. If none, leave it empty.
I also
have fever
had surgery recently
have a malignant tumor
Write here if you have additional symptoms. You can write more than one. If none, leave it empty.
The last drug I have used for my low back pain
Write here the last medicine you have used for your low back pain. Write its name, stregth and number of doses you have taken in a day.
The drug(s) I have used previously for my low back pain
Write here the medicine(s) you have used previously for your low back pain. Write the name, stregth and number of doses you have taken in a day.
The other drugs I take for other diseases
Write here the medicines you use for other diseases. Write their names, stregth and number of doses you take in a day. If none, leave it empty.
The herbal supplements I use
Write here the herbal supplements you use. Write their names, stregth and number of doses you take in a day. If none, leave it empty.
My other diseases
Write here the other diseases you have. If none, leave it empty.
More information about my problems
Write here the addional information you want your doctor to know and you think has an impact on your problems.
The most important thing I want from the appointment
Write here the most important thing about which you want information or the position of your doctor during your visit. For example, diagnosis, rehabilitation possibilities, the need for surgery, what kind of side effect the treatments might have, the need for a sick leave and so on.
The second most important thing I want from the appointment
Write here the second most important thing about which you want information or the position of your doctor during your visit.
The addtitional important things I want from the appointment
Write here the additional important things about which you want information or the position of your doctor during your visit. Please take into account that the doctor usually has limited time for the reception.
My email address
*
Name