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Your name *

Your age *

Your e-mail address *

Your telephone number

Your address *

Since when do you have pain and where? *

Do you blame any event for these complaints (e.g. accident, heavy lifting..) *

In which position your complaints are worst? (lying down, sitting, standing, walking?) *

By which actions do you get relief? (e.g. bending forward, sitting..) *

Do you experience pins and needles or numbness, temporarily or continuous? *

Do you have a restriction in motion range, loss of strength? *

Have you got images? Which ones? When? Result? *

Which diagnoses have been established up to now? *

Have you been operated upon already or is operation recommended? *

Additional remarks

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