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Access to the affected area to learn more about your injuryAPPOINTMENT REQUEST
If you are already in treatment and want to request a review, you can use the review form:
Check-up form
If it is the first time you come or it is for a new treatment, please, fill in the following form:
Name (*):
First surname (*): Second surname:
Telephone(s) (*): Email (*):
Address (*):
City or town (*): Postal code (*):
ID (*): Birthdate 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February Marz April May June July August September October November December 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924
Height (*): Weight (*):
: Occupation/job (*): -- SELECT -- Right-handed Left-handed Ambidextrous
How you heard about us (*):
Where is your problem located? (please select)
Shoulder: Knee: -- SELECT -- Right Left Both -- SELECT -- Right Left Both
Hip: Ankle: -- SELECT -- Right Left Both -- SELECT -- Right Left Both
Elbow: Wrist: -- SELECT -- Right Left Both -- SELECT -- Right Left Both
If other, please specify:
Symptoms (please select)
Pain: Weakness: -- SELECT -- Yes No -- SELECT -- Yes No
Instability: Stiffness: -- SELECT -- Yes No -- SELECT -- Yes No
Swelling: -- SELECT -- Yes No
Is the pain the result of a trauma, accident or other? -- SELECT -- Yes No
If yes, please tell us the date and give a brief description of how it came about (sport, work, traffic accident, etc):
If it is a sports injury, please tell us which level (amateur, professional, etc):
How long have you had symptoms?
Diagnosis (if you know):
Do you take medication for pain? -- SELECT -- Yes No
If yes, say which Aspirin, Paracetamol, Anti-inflammatory medication, etc:
How severe is the pain? On a scale of 0 (no pain) to 10 (very severe pain):
When resting: When it hurts most: -- SELECT -- 0 (no pain) 1 2 3 4 5 6 7 8 9 10 (strong pain) -- SELECT -- 0 (no pain) 1 2 3 4 5 6 7 8 9 10 (strong pain)
Does it hurt at night? Are you awoken by pain? -- SELECT -- Yes No -- SELECT -- Yes No
You have pain in...? -- SELECT -- Groin Gluteus Low back Lateral thigh Other place
Observations:
In which situations does it hurt LESS? Mark them:
In which situations does it hurt MORE? Mark them:
In which part of the shoulder do you feel the pain? -- SELECT -- Front part In the shoulder Neck part Others (observations)
In which part of the elbow do you feel the pain? -- SELECT -- On the sides Front part On the back part Other place
Where is your wrist\'s/hand\'s pain?: -- SELECT -- Wrist Fingers Thumb base Other place
Do you feel strength-loss? -- SELECT -- Yes No
Is your mobility limited -- SELECT -- Yes No
Do you feel prickling (Shoulder)? -- SELECT --
Do you feel sensibility-loss (Shoulder)? -- SELECT --
Do you feel prickling (Elbow)? -- SELECT --
Do you feel sensibility-loss (Elbow)? -- SELECT --
Do you feel prickling (Wrist-Hand)? -- SELECT --
Do you feel sensibility-loss (Wrist-Hand)? -- SELECT --
Do you feel joint blocking? -- SELECT -- Yes No
Describe your current limitations:
Do you have any imaging tests? Please select and provide the date(s):
- : -- SELECT -- Yes No Test date:
- MRI scan: -- SELECT -- Yes No Test date:
- CT scan: -- SELECT -- Yes No Test date:
Have you been diagnosed with arthrosis before? -- SELECT -- Yes No
If yes, please say which joint and provide the date of diagnosis:
Have you ever had the joint injected with hyaluronic acid, cortico-steroids and/or PRGF? : -- SELECT -- Yes No
If yes, say which, in which joint and the date:
Do you take any medicine specifically for arthrosis? -- SELECT -- Yes No
If yes, say which:
Are you allergic to any medicine? -- SELECT -- Yes No
If so, please say which medicine
Do you have any hereditary illness? -- SELECT -- Yes No
If so, please say which:
Do you have (or have you had) any heart problems? -- SELECT -- Yes No
Do you have gastritis / a gastric ulcer? -- SELECT -- Yes No
Are you diabetic? -- SELECT -- Yes No
Do you have liver problems / hepatitis? -- SELECT -- Yes No
Do you have any kidney disease? -- SELECT -- Yes No
Do you have problems of blood-clotting? -- SELECT -- Yes No
Are you a smoker? Do you consume alcoholic drinks? -- SELECT -- Regular smoker Occasional smoker Ex-smoker Non smoker -- SELECT -- Every day Occasionally Weekends Never
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