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Your First Name
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Your Last Name
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Birth date
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Your Address
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Phone number
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Profession
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Sex
F
M
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Referral
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Reason for consulting
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Medical problems(select one or multiple)
High blood tension
High cholesterol levels
High blood sugar levels
Pneumonia in the past 2 years
Cancer
HIV
Substance addiction
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Surgeries
No
Yes (please specify)
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Specify Surgery
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Family hereditary problems
No
Yes (please specify)
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Specify Problem
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Medication
No
Yes (please specify)
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If yes divided into 2 categories
Pain medication or medication related to your pain
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Medications related to your medical problem
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Did you perform any injection in your painful area before?
No
Yes (please specify)
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Specify the injection
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Did you undergo a specific surgery in the area you are coming to consult for?
No
Yes (please specify)
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Specify the surgery
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Did you undergo any trauma in the area you are coming to consult for?
No
Yes (please specify)
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Specify
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Did you do physiotherapy or any kind of rehabilitation before?
No
Yes (please specify)
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How many sessions
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What kind of rehabilitation
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Area or areas of pain (pick one or many)
Neck pain or Headaches
Shoulder pain
Elbow pain
Wrist pain
Low back pain
Hip problem
Knee problem
Ankle Problem
[{"field":"","logic":"","value":"","and_method":"","field_and":"","logic_and":"","value_and":""}]
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Others (please specify)
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Neck pain or Headaches
Does the pain wake you up at night?
No
Yes
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Is the pain is more acute in the morning?
No
Yes
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Please select the symptoms you are feeling to help us diagnose you better
Headache in the morning
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Pain wakes you up at night
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Irradiation to your arms
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Right
Left
[{"field":"{field_WGXNP}","logic":"equal","value":"Irradiation to your arms","and_method":"","field_and":"","logic_and":"","value_and":""}]
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Tingling in your fingers
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Stomach pain and reflux
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Vertigo or dizziness
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Imbalance
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Nausea and vomiting
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Photophobia
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Phonophobia
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Ora
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Pulse pain
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Constant pain
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Can you specify your pain in a point?
No
Yes (if yes specify)
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Specify pain
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Does your pain follows a specific trajectory?
No
Yes (if yes specify)
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Specify trajectory
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[{"field":"{option_2}","logic":"contains","value":"Neck pain or Headaches","and_method":"","field_and":"","logic_and":"","value_and":""}]
Shoulder pain
Please select the symptoms you are feeling to help us diagnose you better
Anterior pain
Posterior pain
Lateral pain
Biceps pain
Irradiating pain
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Does the pain wake you up at night?
No
Yes
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Does the pain increase during work?
No
Yes
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Does the pain is more acute in the morning?
No
Yes
Field is required!
Does the pain go away with any medication?
No
Yes
Field is required!
[{"field":"{option_2}","logic":"contains","value":"Shoulder pain","and_method":"","field_and":"","logic_and":"","value_and":""}]
Elbow pain
Does the pain wake you up at night?
No
Yes
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Does the pain affect your functionality?
No
Yes
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Do you have any impossible movement to do?
No
Yes
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Can you specify your pain in a point?
No
Yes(if yes specify where)
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Specify where
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[{"field":"{option_2}","logic":"contains","value":"Elbow pain","and_method":"","field_and":"","logic_and":"","value_and":""}]
Wrist pain
Can you lift things without having pain?
No
Yes
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Can you specify your pain in a point?
No
Yes(if yes specify where)
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Specify where
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Does your pain wake you up at night?
No
Yes
Field is required!
Do you have any difficulty to move your fingers?
No
Yes
Field is required!
[{"field":"{option_2}","logic":"contains","value":"Wrist pain","and_method":"","field_and":"","logic_and":"","value_and":""}]
Low back pain
Select one or multiple choice
Central pain
Irradiation to lower limb
Tingling in one or both lower limb
Loss of power in one of your lower limbs
Reduction in the walking distance
Pain wakes you up at night
Spasm in the lower back
Hip related problem
Fever
Buttock pain
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Is your pain more acute in the morning ?
No
Yes
Field is required!
Does you pain increase while walking ?
No
Yes
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Does your pain go when you lay down on your back ?
No
Yes
Field is required!
Do you have difficulty standing up from a chair ?
No
Yes
Field is required!
Do you have flat feet ?
No
Yes
Field is required!
[{"field":"{option_2}","logic":"contains","value":"Low back pain","and_method":"","field_and":"","logic_and":"","value_and":""}]
Hip problem
Select one or multiple choice
Does the pain wake you up at night
Irradiation to the buttock
Irradiation to the lower limb
Anterior pain
Posterior pain
Mechanic pain
Fever
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Does the pain increase on the stairs ?
No
Yes
Field is required!
Do you have difficulty walking out the vehicle?
No
Yes
Field is required!
Do you have difficulty while doing sports?
No
Yes
Field is required!
Do you have difficulty waking up in the morning?
No
Yes
Field is required!
Do you have flat feet ?
No
Yes
Field is required!
[{"field":"{option_2}","logic":"contains","value":"Hip problem","and_method":"","field_and":"","logic_and":"","value_and":""}]
Knee problem
Select one or multiple choice
Does the pain wake you up at night
Stiffness in the morning - تصلب و تجنج في الصباح
Pain while going up the stairs
Pain while going down the stairs
Cracks on every move
Front pain
Rear pain
Swelling
Pain on jumping
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Do you have flat feet ?
No
Yes
Field is required!
[{"field":"{option_2}","logic":"contains","value":"Knee problem","and_method":"","field_and":"","logic_and":"","value_and":""}]
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