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Read about the BACKRACK and more on THE LUKLINSKI' SPINE CARE site!

The Patented Back Rack - Brings instant relief from back pain!

Telephone: +44(0)207-631-3067 Emergencies: +44(0)7710-901140
THE LUKLINSKI' SPINE CLINIC
Suite 17, Milford House - 7 Queen Ann St. (off Harley St.), London, W1G 9HN
Established 1969 - over 40 years experience in treating spinal disorders
Share your experience at our DISCUSSION FORUMS Polish version Arabic version
Mr. Luklinski

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since 1st Jan 2011

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CONSULTATION FORM
by Mr. B.M. Luklinski
MSc Medical Rehabilitation; MSc Physical Education; Dip Home Med.

The results of the diagnosis will be emailed to you within a few days depending on our patient work load at the clinic. We may need to contact you by email for further information. Please note this service cannot be a substitute of a thourough physical examination. So our response cannot be relied upon to determine your true condition.

Please read prior to contacting us the Frequent Questions and Answers


NAME   E-MAIL  
(Ensure that your email address is valid!)
Age  
Height  
Weight  
REASONS FOR FILLING THE QUESTIONNAIRE
Please choose all relevant:
 I would like to have a diagnosis and I am ready to book consultation and treatment to get cured.
 I would like to have a diagnosis and I am ready to buy SPINAL MOBILISERS.
 I would like to have a diagnosis but I am not really interested to be treated. I might buy the SPINAL MOBILISERS though.
 I would like to have a diagnosis but I am not really interested to be treated or to buy the SPINAL MOBILISERS.
 Else? Please state:


QUESTIONS ABOUT YOUR PAIN
Where is your pain?
  Neck
 Middle back
 Lower Back
On which side is the pain?
  Left
  Right
  Middle
Any pain elsewhere?
 Leg
 Arm
 Back
When did the pain start?
 Recent
 1+ week
 1+ month
Do you have pain only?
 only pain
 with stiffness
What brings the most relief?
 Rest
 Movement
 Sitting
 Lying down on the left side
 Lying down on the right side
Do you have any night pain?
 Yes
 No
Do you have any morning pain?
 Yes
 No
Which makes the pain worse?
 Bending forward
 Bending backward
 Turning left
 Turning right
 Leaning left
 Leaning right
 Walking on a flat surface
 Climbing stairs
 None of these
What action causes more pain?
Do you have numbness or tingling (pins & needles)
Describe your pain:

GENERAL QUESTIONS
1  Any muscular weakness?
 Yes
 No
2  Can you get up from sitting?
 Yes
 No
3  Have any scans been obtained?
 Yes
 No
4  Have you taken anabolic steroids?
 Yes
 No
5  Do you suffer from vertigo?
 Yes
 No
6  Any headaches?
 Yes
 No
7  Any weight loss recently?
 Yes
 No
8  Any urinal or bowel problems?
 Yes
 No
9  Are you taking medication?
 Yes
 No
10  Have you been examined?
 Yes
 No
11  Surgery advised?
 Yes
 No
12 Would you consider surgery?
 Yes
 No
How is your condition generally during the day?
Evening  Midday  Afternoon 
Since the problem started are you:
 Better
 Worse
 No change
What practitioner have you seen?

What diagnosis have you been given?

What treatment have you received for your condition?

Please provide any additional information or queries you may have.


If you live in the UK you may wish to call us: 0207-631-3067
Please provide a telephone number: