Spinal Flow Senteret — Mapping form

  • Spinal Flow Senteret — Mapping form

  • NB: (ONLY TO BE FILLED OUT BEFORE BOOKING INTRODUCTION SESSION)

    This is a form that serves to map out your condition and situation at the start of treatment.
    It is important that you answer as honestly and accurately as possible.

    *The information will not be used for purposes other than those stated.
    **(Confidentiality and data security (GDPR) are maintained)

  • Personal information

  • Date of Birth*
     - -
  • How did you hear about Spinal Flow Senteret?*

  • Relevant medical information:

    Leave the field blank if the question is not applicable.

  • Symptoms / Ailments

  • Give each symptom a score between 0 and 3:
    0 = Not bothered
    1 = A little bothered
    2 = Bothered quite a lot
    3 = Bothered significantly (affects you daily/frequently or limits your life)

    Feel free to write additional text afterward for any points you may want to elaborate on.

  • Rows
  • Should be Empty: