EmailMeForm
ThePain.net neck 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 all the relevant information. Your doctor may get a clearer picture and have 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.
Fields marked with an asterisk are required to send the form.
My neck pain began
*
Write here the time you had first neck pain.
My neck pain began
little by little.
suddenly.
I have had
a trauma of my neck.
no trauma of my neck.
The type and date of the trauma:
Write here the date of the trauma of your neck and describe its character. If none, leave it empty.
My neck pain got worse
Write here the last time you neck pain got worse. If none, leave it empty.
My pain can be characterized as
Write here the character of your neck 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 neck pain on a scale o 0-10. (0=no pain - 10=worse pain ever)
This is my
*
first episode of neck pain.
second episode of neck pain.
third or more than third episode of neck pain.
Previous episodes of my neck pain lasted for
Write here the duration of the previous episodes of your neck pain. If none, leave it empty.
Neck pain started this time
in connection with heavy lifting or other hard work.
in connection with a direct blow or a neck trauma.
in connection with a sudden movement or a sports performance.
in connection with long hours on computer or with similar conditions.
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 back line of the neck, the pain is felt
in the middle.
on the right side.
on the left side.
along the entire width of the neck.
elsewhere:
Choose the best option or write it in the free space.
Pain is felt in an up-down direction
in the back of the head.
above the hairline.
below the hairline.
on the shoulder level.
on the shoulder blade level.
on other level:
Choose the best option or write it in the free space.
My neck pain gets worse when
Write here what makes your neck pain worse.
My neck pain gets better when
Write here what makes your neck pain better.
My neck 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 neck pain
*
wakes me up every night.
wakes me up sometimes.
does not wakes me up.
Choose the best option.
My neck
*
has been operated.
has not been operated.
The neck surgery was
If your neck was operated, write here the time and the type of the operation.
I have
*
fecal incontinence problems.
urinary incontinence problems.
weakness or paralysis of the right arm or leg.
weakness or paralysis of the left arm or leg.
weakness or paralysis of both the right and left arm or leg.
no arm or leg weakness or paralysis.
My neck pain also
*
radiates to the arm or further.
does not radiate to the arm or further.
The worst radiation is
to the right upper arm.
to the right thumb or its side of the forearm.
to the right middle finger.
to the right little finger or its side of the forearm.
to the right little finger side of the elbow.
to the left upper arm.
to the leftt thumb or the thumb side of the forearm.
to the leftt middle finger.
to the left little finger or its side of the forearm.
to the left little finger side of the elbow.
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
in the right upper arm.
in the right thumb or its side of the forearm.
in the right middle finger.
in the right little finger or its side of the forearm.
in the right little finger side of the elbow.
in the left upper arm.
in the leftt thumb or the thumb side of the forearm.
in the leftt middle finger.
in the left little finger or its side of the forearm.
in the left little finger side of the elbow.
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 have additionally
fever
headache
dizziness
problems with balance
nausea
seizures or loss of consciousness
involuntary muscle twitching and head turning
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 neck pain
Write here the last medicine you have used for your neck pain. Write its name, stregth and number of doses you have taken in a day.
The drug(s) I have used previously for my neck pain
Write here the medicine(s) you have used previously for your neck 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