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.
  • Write here the time you had first neck pain.
  • Write here the date of the trauma of your neck and describe its character. If none, leave it empty.
  • Write here the last time you neck pain got worse. If none, leave it empty.
  • Write here the character of your neck pain. For instance sharp, dull, burning, throbbing etc.
  • Write here your estimate of the intensity of your neck pain on a scale o 0-10. (0=no pain - 10=worse pain ever)
  • Write here the duration of the previous episodes of your neck pain. If none, leave it empty.
  • Choose the best option or write it in the free space.
  • Choose the best option or write it in the free space.
  • Choose the best option or write it in the free space.
  • Write here what makes your neck pain worse.
  • Write here what makes your neck pain better.
  • Choose the best option.
  • Choose the best option.
  • If your neck was operated, write here the time and the type of the operation.
  • If you had radiating pain write it here. Choose the best option or write it in the free space.
  • If you have numbness or tingling write it here. Choose the best option or write it in the free space.
  • Write here if you have pains in other areas. If none, leave it empty.
  • Write here if you have additional symptoms. You can write more than one. If none, leave it empty.
  • 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.
  • 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.
  • 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.
  • 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.
  • Write here the other diseases you have. If none, leave it empty.
  • Write here the addional information you want your doctor to know and you think has an impact on your problems.
  • 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.
  • Write here the second most important thing about which you want information or the position of your doctor during your visit.
  • 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.