Clinique solutions discales Online evaluation Name * Gender* ManWoman Date of birth* City / State Country Where do you feel the pain? When did you feel that pain for the first time? Specify your pain —Please choose an option—Lower backCervicale Which position or movement is the worst for you? FlexionExtensionRotationOther Did you ever have one of theses diagnostics for your problem? Herniated discDisc degenerative diseaseLumbar arthrosisSpinal stenosis Do you or did you have one of theses medical diseases? CancerInflammatory diseaseSpine fracture Which position or movement is the worst for you? Lying on the backSittingStandingWhen walkingAlways thereOther Did you ever have one of theses diagnostics for your problem? Herniated discDisc degenerative diseaseLumbar arthrosisSpinal stenosisSciaticaScoliosis Do you or did you have one of theses medical diseases? CancerInflammatory diseaseSpine fracture Have you ever been diagnosed with severe osteoporosis following an examination that measures bone density (bone densitometry)? —Please choose an option—OuiNon Did you ever have one of these imaging for your concern problem : X-ray —Please choose an option—YesNo MRI —Please choose an option—YesNo Do you have a copy of the written medical reports? —Please choose an option—YesNo **If you answer yes to one of these questions, we strongly suggest to bring a written copy of the result at the evaluation, if possible. Where did you heard about our clinic? TelevisionRadioNewspapersFrom a friend or your doctorInternetOther Email adress * Better phone number to join you * Best time to reach you 8h-10h10h-12h12h-14h16h-18h Would you like to make an appointment directly online? Make an appointment Commentary
