Spinal Assessment

Before your appointment

Please complete this short questionnaire before your appointment. It helps Prof Kruger understand where your problem is and how urgent it is. It takes about 5 minutes, and questions marked * are required.

Prefer paper? Download the printable PDF versionand email or bring it to the rooms.

    1About you

    Sex

    2Where do you feel it?

    Choose what you are marking, then tap each area of the body where you feel it. You can mark the same area for both. To remove a mark, choose the same symptom and tap the area again, or use the × in the list below the map.

    Pain in the middle of the spine? Tap here too:

    Tip: on a phone, use the buttons above to switch between the front, the back of the legs, the head and the hands. You can also zoom in with two fingers.

    What do your symptoms feel like? (tick all that apply)

    3About your symptoms

    How long have you had this pain?

    Is it getting better over the past few days or week?

    Can you walk a normal distance?

    Is the pain relieved by lying down?

    Any change in bladder or bowel control (leaking, or difficulty passing urine)?

    Any weakness or clumsiness in the legs, arms or hands?

    Can you stand on tiptoe and on your heels?

    Any loss of weight?

    How many days a week are you taking painkillers?

    4Pain scores

    Select the number that best describes your pain (0 = no pain, 10 = worst pain possible).

    What is your pain right now?

    0 = no pain10 = worst pain possible

    What is your typical or average pain?

    0 = no pain10 = worst pain possible

    At its best, how close to 0 does your pain get?

    0 = no pain10 = worst pain possible

    At its worst, how close to 10 does your pain get?

    0 = no pain10 = worst pain possible

    5Medical history and scans

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