SpinalSurgeryMexico Questionnaire

  • SPINE PATIENT QUESTIONNAIRE

    Please fill out each field. Thank you

  • If you want to appoint a FREE phone consult call: +1(772)419-8061.

    Or email us: gregorypope@spinalsurgerymexico.com

  • GENERAL INFORMATION

  • Date of Birth*
     / /

  • PAIN DESCRIPTION

  • On the body diagrams use the appropriate pencil to mark where you feel the following sensations:

    - Aching pain
    - Pins and Needles
    - Stabbing Pain
    - Numbness  

    1. Click the black square icon and pick a color.
    2. To draw: click on a spot, keep the pressure and drag over your pad (or use the mouse to move cursor around).

  • 1. When did your present pain start? *
     / /


  • 4. Have you had similar pains in the past?*
  • 5. How did your pain start? Please check (x) all that apply to you.*


  • 8. What activities make your pain worse? Please check (x) all that apply to you.*

  • 9. What reduces your pain? Please check (x) all that apply to you.*

  • 10. What types of treatment have you had? Please check (x) all that apply to you.*

  • 11. Review of symptoms. Please check (x) all that apply to you.*

  • DIAGNOSTIC TESTS

  • Rows
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  • MEDICAL HISTORY

  • ILLNESSES / CONDITIONS. Please check (x) the box next to any illnesses or problems that apply to you.*

  • PAST SURGICAL HISTORY. Please check (x) the box next to any surgical procedures that you have had.*

  • ALLERGIES. Please check (x) the box next to any allergies that apply to you.*

  • Do you have difficulty taking anti-inflammatory medications? *
  • FAMILY HISTORY. Please check (x) the box next to any disease diagnosed in your blood relatives.*

  • WORK AND HABITS



  • Is this the same occupation you had before your injury?*
  • Are you still working? *
  • If you answered NO to previous question, what was last day on the job?*
     / /
  • If working, are you at full duty or light duty? *

  • How should we contact you?
    Please provide email & telephone number with city/country code.

  • No Yahoo nor AOL addresses, we cannot reply to you on those. Please use another mail provider.

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  • Current Date*
     / /
  • Should be Empty: