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ZENTRUM FÜR FUNKTIONSERHALTENDE WIRBELSÄULENCHIRURGIE
Orthopädie und Neurochirurgie Dr. Michael SchubertDr. Armin Helmbrecht
APEX SPINE CENTERHelene-Weber-Allee 1980637 München
Telefon/Fax: +49 (0)700 20 4000 20 Web: www.apex-spine.comE-Mail: [email protected]
Motion preservation spinesurgery
surname
city
fax
general informations
first name
date of birth
adress
country
contact informations
phone
mobile
your pain areas
Where in your body is the pain located?
Anamnesis Lumbar SpinePage 1 of 3
Fax: ++49 (0)700 20 4000 20
ZENTRUM FÜR FUNKTIONSERHALTENDE WIRBELSÄULENCHIRURGIE
Orthopädie und Neurochirurgie Dr. Michael SchubertDr. Armin Helmbrecht
APEX SPINE CENTERHelene-Weber-Allee 1980637 München
Telefon/Fax: +49 (0)700 20 4000 20 Web: www.apex-spine.comE-Mail: [email protected]
Motion preservation spinesurgery
Your health complaints
Since when hve you had the current complaints
I have back pain yes no
I have leg pain left right no
I have pain in my fundament ileft right no
When I sneeze or cough the pain increases no little yes
When I lie I have pain no little yes
When I walk I have pain no little yes
When I sit I habe pain no little yes
When I stand I have pain no little yes
What hurts most sitting standing
going lying
Was there a cause for your back/leg problems (e.g. accident, heavy lifting)
Is there a loss of strength in your leg yes no
s there a loss of sensation in your leg yes no
Have you operated on your back yes no
If so, what kind of operation was that and when did it take place
What kind(s) of treatment have you had so far and whar was the result
Anamnesis Lumbar SpinePage 2 of 3
Fax: +49 (0)700 20 4000 20
ZENTRUM FÜR FUNKTIONSERHALTENDE WIRBELSÄULENCHIRURGIE
Orthopädie und Neurochirurgie Dr. Michael SchubertDr. Armin Helmbrecht
APEX SPINE CENTERHelene-Weber-Allee 1980637 München
Telefon/Fax: +49 (0)700 20 4000 20 Web: www.apex-spine.comE-Mail: [email protected]
Motion preservation spinesurgery
Your health complaints
Did you do any sports before the complaints arose yes no
If so, what kind of sport
What is the result/conclusion of the last MRI, MRT or CT
Anamnesis Lumbar SpinePage 2 of 3
Fax: +49 (0)700 20 4000 20
