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Where is Your Pain?

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Home
Our Team

Orthopedics and Traumatology Physical Therapy and Rehabilitation Physical Therapy Technicians Physiotherapists
Patient Information

Where is Your Pain?

Video Gallery

Patient Guide
Treatments
Contact Us

Online Consultation

1

Personal Information

2

Medical Condition

3

Medical Files

4

Select Dates

5

Payment

Name and Surname:* E-mail:*

Country Please provide your phone number below with the country code:* Your height in cm:* Your weight in kg:* Your date of birth:

Spinal Regions

Cervical Spine (Neck) Upper Back (Thoracic Spine)

Middle Back Lower Back (Lumbar Spine)

Upper Extremities

Left Shoulder Right Shoulder

Left Elbow Right Elbow

Left Wrist Right Wrist

Left Hand Right Hand

Lower Extremities

Left Hip Right Hip

Left Knee Right Knee

Left Ankle Right Ankle

Left Foot Right Foot

Please describe your pain and symptoms:

None Very Mild Mild Moderate Severe

Rarely/Never Sometimes or just at first Often, not just at first Most of the time All of the time

No pain > 60 minutes 16 to 60 minutes 5 to 15 minutes Around the house only Not at all - severe on walking

1-3 months 3-6 months 6-12 months 1-2 years 2+ years

Standing Sitting Kneeling Laying Walking Bending Climbing Stairs Other

Hypertension Diabetes Asthma Heart Disease Liver Disease Allergy Renal Diseases Neurological Diseases Cancer Infectional Diseases I do not have any other chronic diseases or diagnosis Other

Yes No

Describe your complaints as a whole story.

Please upload your medical files below:*
(Only rar and zip files are allowed)

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Name on card

Card Number

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Expiration date

CVV

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Where is Your Pain?

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