Spine Health Form - Medijourn

Choose your condition

Experienced back pain for more than 3 months.

Experienced neck pain for more than 3 months.

Experienced neck pain and arm pain.

Experienced back pain and leg pain.

Experienced arm or leg numbness on either side.

Experienced arm or leg weakness on either side.

I feel out of balance (swing side to side) while walking.

I have been recommended surgery in the past.

Choose your X-ray or MRI results:

A hospital asked me to go through surgery.

I have had X-ray and MRI scans for thoracic or lumbar spine

I have had a cervical spine X-ray.

I have had a cervical spine MRI scan.

I have undergone a thoracic or lumbar spine X-ray.

I have undergone a thoracic or lumbar spine MRI scan.

I have not undergone any X-ray or MRI scan.

Numbness and tingling in extremities of body?

Yes

No

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I certify that the personal data filled in this form is true, correct and current. In case I fill in on behalf of other persons, I confirm that I have obtained their consent or have a legal right to disclose their personal data to the Hospital.

Consent
I grant my consent to the Hospital to collect, analyze, process, use and disclose my personal data and send me information about products, services, advertisements, or promotional campaigns that will benefit me through all channels I have provided to the hospital.

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Do Not Accept

Health Risk Assessment

Spine Health

Acknowledgements and Certification

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