Suite 17, Milford House - 7 Queen Ann St.

(off Harley St.), London, W1G 9HN

Telephone:

+44(0)207-631-3067

Emergencies:

+44(0)7710-901140

  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


Age

Height

Weight

REASONS FOR FILLING THE QUESTIONNAIRE

Please choose all relevant:


QUESTIONS ABOUT YOUR PAIN

Where is your pain?

On which side is the pain?

Any pain elsewhere?

When did the pain start?

Do you have pain only?

What brings the most relief?

Do you have any night pain?

Do you have any morning pain?

Which makes the pain worse?

What action causes more pain?

 

Do you have numbness or tingling (pins & needles)

Describe your pain:

 


GENERAL QUESTIONS

1  Any muscular weakness?

2  Can you get up from sitting?

3  Have any scans been obtained?

4  Have you taken anabolic steroids?

5  Do you suffer from vertigo?

6  Any headaches?

7  Any weight loss recently?

8  Any urinal or bowel problems?

9  Are you taking medication?

10  Have you been examined?

11  Surgery advised?

12 Would you consider surgery?

How is your condition generally during the day?

Evening

Midday

Afternoon

Since the problem started are you:

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.