Please provide the following information about your condition.
First Name
*
Last Name
*
Date Of Birth
*
Phone
*
Email Address
*
How did you find out about BackSpace?
SpinePlus
Axxon Pain
Specialist
GP
Allied health professional
Word-of-mouth
Social media
Online
Previous patient
Have you had any treatment for this condition?
Yes
No
Please specify what treatment you have had:
Surgery
Injections
Rehabilitation
Other
Details:
Where are your symptoms?
*
Neck
Arm
Back
Leg
Neck
Is your pain the result of a car accident, fall or crush injury?
Yes
No
Did you present to the emergency room within 48 hours of your accident?
Yes
No
Arm
Do you have numbness, pins and needles or tingling in the shoulder, arm or hand?
Yes
No
Do you have severe weakness in your arms or hands?
Yes
No
Do you have difficulty using BOTH of your arms or hands?
Yes
No
Do you have difficulty pushing, pulling or lifting objects with one or both arms?
Yes
No
Back
Is your pain the result of a car accident, fall or crush injury?
Yes
No
Did you present to the emergency room within 48 hours of your accident?
Yes
No
Leg
Do you have severe weakness in BOTH legs?
Yes
No
Do you have trouble standing or walking more than a few steps unaided because of weakness?
Yes
No
Do you have severe numbness or pins and needles in your groin or down one or both legs?
Yes
No
Have you developed inability to urinate or loss of control of your bladder?
Yes
No
Have you noticed any weakness in ONE foot?
Yes
No
Have you noticed that your foot drags, flops or catches when you walk?
Yes
No
Do you have severe pain in ONE leg?
Yes
No
Duration
How long have you had the pain?
less than 6 weeks
between 6 and 12 weeks
more than 12 weeks
Severity
Are you able to do the following daily activities?
Able
Limited
Unable
Bath/shower
Able
Limited
Unable
Dress yourself
Able
Limited
Unable
Walk short distances
Able
Limited
Unable
Drive/catch public transport
Able
Limited
Unable
Clean the house
Able
Limited
Unable
Garden/mow
Able
Limited
Unable
Work
Able
Limited
Unable
Medication
Are you taking any pain medication?
Yes
No
How effective is this medication in relieving your pain?
Complete relief of pain
Partial relief of pain
Very little relief of pain
No effect on pain
Imaging
Have you had any previous scans related to your condition?
MRI
CT
Xray
No
Which radiology clinic performed your scans?
Brisbane Private Imaging
Queensland Xray
Qscan
I-MED
QDI
Other
Please specify:
Financial
How will you be claiming your BackSpace visit?
Private health insurance
Self-funded
WorkCover
DVA
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