Case File

First Name
الاسم
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Field is required!
Your Last Name
الشهرة
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Field is required!
Birth date / تاريخ الميلاد
dd/mm/yy
Field is required!
Field is required!
Your Address
عنوان السكن
Field is required!
Field is required!
Phone number
رقم الهاتف
Field is required!
Field is required!
Profession
المهنة
Field is required!
Field is required!
Sex / الجنس
Field is required!
Field is required!
Referral
المرسل
Field is required!
Field is required!
Reason for consulting
سبب الاستشارة
Field is required!
Field is required!
Medical problems(select one or multiple)

مشاكل طبية حدد واحدًا أو أكثر

Field is required!
Field is required!
Surgeries / عمليات جراحية
Field is required!
Field is required!
Specify Surgery
حدد نوع العملية
Field is required!
Field is required!
Family hereditary problems / مشاكل عائلية وراثية
Field is required!
Field is required!
Specify Problem
حدد نوع مشكلة
Field is required!
Field is required!
Medication / دواء
Field is required!
Field is required!
If yes divided into 2 categories

إذا كانت الإجابة بنعم اقسمها إلى فئتين

Pain medication or medication related to your pain
دواء للألم
Field is required!
Field is required!
Medications related to your medical problem
الدواء المتعلق بمشكلتك الطبية أو المزمنة
Field is required!
Field is required!
Did you perform any injection in your painful area before?

هل أجريت أي حقنة في المنطقة المؤلمة من قبل

Field is required!
Field is required!
Specify the injection
حدد نوع الحقنة
Field is required!
Field is required!
Did you undergo a specific surgery in the area you are coming to consult for?

هل خضعت لعملية جراحية معينة في المنطقة التي أتيت للاستشارة عنها؟

Field is required!
Field is required!
Specify the surgery
حدد نوع العملية
Field is required!
Field is required!
Did you undergo any trauma in the area you are coming to consult for?

هل تعرضت لأي صدمة في المنطقة التي أنت قادم للاستشارة عنها؟

Field is required!
Field is required!
Specify
حدد
Field is required!
Field is required!
Did you do physiotherapy or any kind of rehabilitation before?

هل أجريت أي علاج فيزيائي أو أي نوع من إعادة التأهيل من قبل؟

Field is required!
Field is required!
How many sessions
عدد الجلسات
Field is required!
Field is required!
What kind of rehabilitation
أي نوع من العلاج التأهيلي
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Field is required!
Area or areas of pain (pick one or many)

منطقة أو مناطق الآلام حدد واحدًا أو أكثر

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Field is required!
Others (please specify)
غير ذلك يرجى التحديد
Field is required!
Field is required!

Neck pain or Headaches
آلام الرقبة والصداع

Does the pain wake you up at night?

هل يوقظك الألم في الليل؟

Field is required!
Field is required!
Is the pain is more acute in the morning?

هل يكون الألم أكثر حدة في الصباح؟

Field is required!
Field is required!
Please select the symptoms you are feeling to help us diagnose you better

يرجى تحديد الأعراض التي تشعر بها لمساعدتنا في تشخيص حالتك بشكل أفضل

Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Can you specify your pain in a point?

هل يمكنك تحديد ألمك في نقطة؟

Field is required!
Field is required!
Specify pain
حدد الألم
Field is required!
Field is required!
Does your pain follows a specific trajectory?

هل يتبع الألم مسارًا محددًا؟

Field is required!
Field is required!
Specify trajectory
حدد المسار
Field is required!
Field is required!

Shoulder pain
الم الكتف

Please select the symptoms you are feeling to help us diagnose you better

يرجى تحديد الأعراض التي تشعر بها لمساعدتنا في تشخيص حالتك بشكل أفضل

Field is required!
Field is required!
Does the pain wake you up at night?

هل يوقظك الألم في الليل؟

Field is required!
Field is required!
Does the pain increase during work?

هل يزداد الألم أثناء العمل؟

Field is required!
Field is required!
Does the pain is more acute in the morning?

هل يكون الألم أكثر حدة في الصباح؟

Field is required!
Field is required!
Does the pain go away with any medication?

هل يزول الألم بأي دواء؟

Field is required!
Field is required!

Elbow pain
إذا ألم الكوع

Does the pain wake you up at night?

هل يوقظك الألم في الليل؟

Field is required!
Field is required!
Does the pain affect your functionality?

هل يؤثر الألم على وظائفك و حركتك؟

Field is required!
Field is required!
Do you have any impossible movement to do?

هل لديك أي حركة مستحيل القيام بها؟

Field is required!
Field is required!
Can you specify your pain in a point?

هل يمكنك تحديد ألمك في نقطة؟

Field is required!
Field is required!
Specify where
حدد المكان
Field is required!
Field is required!

Wrist pain
إذا ألم الرسغ

Can you lift things without having pain?

هل تستطيع رفع الأشياء بدون ألم؟

Field is required!
Field is required!
Can you specify your pain in a point?

هل يمكنك تحديد ألمك في نقطة؟

Field is required!
Field is required!
Specify where
حدد المكان
Field is required!
Field is required!
Does your pain wake you up at night?

هل يوقظك الألم في الليل؟

Field is required!
Field is required!
Do you have any difficulty to move your fingers?

هل تجد صعوبة في تحريك أصابعك؟

Field is required!
Field is required!

Low back pain
ألم أسفل الظهر

Select one or multiple choice

اختر واحدًا أو أكثر

Field is required!
Field is required!
Is your pain more acute in the morning ?

هل يكون الألم أكثر حدة في الصباح؟

Field is required!
Field is required!
Does your pain increase while walking ?

هل يزداد الألم أثناء المشي؟

Field is required!
Field is required!
Does your pain go when you lay down on your back ?

هل يزول ألمك عندما تستلقي على ظهرك؟

Field is required!
Field is required!
Do you have difficulty standing up from a chair ?

هل تجد صعوبة في الوقوف عندما تكون جالسن على الكرسي؟

Field is required!
Field is required!
Do you have flat feet ?

هل لديك قدم مسطحة؟

Field is required!
Field is required!

Hip problem
مشكلة الورك

Select one or multiple choice

اختر واحدًا أو أكثر

Field is required!
Field is required!
Does the pain increase on the stairs ?

هل يزداد الألم على الدرج؟

Field is required!
Field is required!
Do you have difficulty walking out the vehicle?

هل تجد صعوبة في الخروج من السيارة؟

Field is required!
Field is required!
Do you have difficulty while doing sports?

هل تجد صعوبة أثناء ممارسة الرياضة؟

Field is required!
Field is required!
Do you have difficulty waking up in the morning?

هل تجد صعوبة في المشي عند الاستيقاظ؟

Field is required!
Field is required!
Do you have flat feet ?

هل لديك قدم مسطحة؟

Field is required!
Field is required!

Knee problem
مشكلة الركبة

Select one or multiple choice

اختر واحدًا أو أكثر

Field is required!
Field is required!
Do you have flat feet ?

هل لديك قدم مسطحة؟

Field is required!
Field is required!

Ankle Problem
مشكلة الكاحل

Select one or multiple choice

اختر واحدًا أو أكثر

اختر واحدًا أو أكثر
Field is required!
Field is required!
Do you have difficulty walking ?

هل تجد صعوبة في المشي عند الاستيقاظ؟

Field is required!
Field is required!
Do you have flat feet ?

هل لديك قدم مسطحة؟

Field is required!
Field is required!