New Consultation for Neck Pain including Brachialgia

Please complete this form prior to your consultation.

The information will help us in determining a diagnosis and treatment.

Please note that all information is kept strictly confidential and will not be disclosed to any third parties.

Is it worse on one side of the spine ? *
Does your neck feel stiff in the mornings but gets better after a while ?
Is the pain worse at the end of the day or when you sit for long periods in front of a computer ? ?
Is pain is worse after impact sports such as tennis or football ?
Does pain refer into one or both arms below the shoulders ?
Is there weakness in one or both arms ?
Is there numbness in one or both arms ?
How long have you had these symptoms *
Is pain is better when you lie down ?
Do you have any problems in controlling bowels or urine ? *

Neck Disability Questionnaire This questionnaire has been designed to give us information about the severity of your neck pain. Please answer every question by selecting the answer that best describes your condition today. We realise you may feel that two of the statements may describe your condition, but please select only the single answer which most closely describes your current condition.
Section 1 - Pain Intensity *
Section 2 – Personal Care (Washing, dressing, etc.)
Section 3 – Lifting *
Section 4 – Reading *
Section 5 – Headache *
Concentration *
Work *
Driving *
Sleeping *
Recreation *