Tekst od meil:

Dear Hristo,

After numerous attempts and updating the DICOM software, I was now able to examine the MR images
of MISHEVSKA-PERCHINKOVA SNEZANA. The pathology of the spine is pronounced after all:

- pronounced left convex rotational scoliosis of the lumbar spine (parietal vertebra L2)

- Z.n.OP L5/S1 with floor plate impression L5 and absolute discal neuroforamen stenosis on the left,
compression of the nerve root L5 on the left

- Vertebral body edema L5 and S1

- Protrusions L1 - L5

- erosive osteochondrosis L1/2 and L2/3

- Facet arthroses L2/3 right, L3/4 on both sides, L4/5 on the left

- additional hydronephrosis on the right

I have enclosed a pain questionnaire (in German), please have Prof. Perchinkova fill it out and return it to
me. This is the best way for me to make a treatment decision.

I would then be happy to organize the treatment including a cost estimate.

Best regards

Sigi
Teks od prasalnik:

Pain questionnaire

1. Patient name (first and last name): ______________________________

2. Date of birth: _____________________________

3. Gender ◻︎m ◻︎w Height (cm): _____ Body weight (kg): ____

4. Address: ................................................ .................ZIP / City: ................. .......................

5. Tel. No.:................................................ ...... Email: .......................................... .............................

6. Nationality: .......................................... Mother tongue: ..... ................................................ .....

7. Are you currently employed? ◻︎yes ◻︎no

If no, please tick the appropriate box:

◻︎Rehab benefit (limited until.......................) ◻︎Pupil/student ◻︎Unemployed ◻︎Occupational disability

8. Are you in ongoing proceedings (rehabilitation benefit, pension application, disability pension,
compensation)? ◻︎yes ◻︎no

9. Planned measures? ◻︎Cure ◻︎Rehabilitation ◻︎Other therapies

10. Are you currently on sick leave? ◻︎yes ◻︎no

11. Current job: _____________________________________________

12. Please describe your pain and the current situation in short words:

Is there a specific trigger or cause? When did the pain first appear? In what situation does it appear?

................................................ ................................................ ..............................

................................................ ................................................ ..............................

................................................ ................................................ ..............................

................................................ ................................................ ..............................

................................................ ................................................ ..............................

................................................ ................................................ ..............................

13. How long have the symptoms existed?

◻︎for .............years ◻︎for ..............months ◻︎exact date:............ ..............

15. Is the pain:

◻︎pressing ◻︎knocking ◻︎burning ◻︎electrifying

◻︎stabbing ◻︎pulling ◻︎shooting

16. Does the pain radiate?

◻︎no ◻︎yes where?____________________. ◻︎right ◻︎left ◻︎on both sides

17. What cause do you attribute your symptoms to?

◻︎no cause identified

◻︎for an operation which one? .............................................

◻︎Date of operation: ................................

◻︎an accident, which one? .............................................

◻︎Date of the accident: ..................................

◻︎other:................................................. .............................................

18. Duration of pain: You suffer from: (please tick)

◻︎Constant pain (constant pain, no pain-free interval)

◻︎Pain attacks (daily, weekly, monthly) how often?

................................................ .....

◻︎How long do these attacks last? (seconds, minutes, hours, days):

.............................................

19. Is your pain particularly severe at certain times of the day?

◻︎no ◻︎yes: ◻︎in the morning ◻︎during the day ◻︎in the evening ◻︎at night

20. What triggers your pain or makes it worse?:

................................................ ..........................................

◻︎I don't know

21. How can you have a beneficial effect on your pain? (sleeping, lying down, going for a walk,
distraction, changing posture or position)

◻︎................................................ ................................................ ...........................

◻︎I cannot control my pain

23. How has your pain been treated so far?

◻︎No pain treatment so far

◻︎Medicines/infusions

◻︎Infiltrations/blockades

◻︎Physiotherapy (individual therapeutic gymnastics, taping, massages) o Physical therapy (electrotherapy,

◻︎Psychotherapy (talk therapy, relaxation techniques, biofeedback)

◻︎Manual therapy (chiropractic, osteopathy, craniosacral therapy,...)

◻︎Spa/rehab/hospital stays (number):_____________

◻︎other: ............................................ .............................................

◻︎Were these helpful?

◻︎yes ◻︎partially ◻︎no ◻︎................................................ ..........................

24. List all operations, indicate the approximate time and side operated on:

1. ................................................ .............................................

2. ................................................ .............................................

3. ................................................ .............................................

25. Please indicate all medications and dosages that you are currently taking (blood pressure, blood
sugar, hormones, dietary supplements, blood thinners,...):

◻︎................................................ ..........................................

◻︎................................................ ..........................................
◻︎................................................ ..........................................

◻︎................................................ ..........................................

27. What pain medications have you taken so far?

◻︎................................................ ..........................................

◻︎................................................ ..........................................

◻︎................................................ ..........................................

◻︎................................................ ..........................................

28. Do you have allergies? (medications, grasses, house dust,...)

◻︎................................................ ..........................................

29. Please indicate other illnesses or consequences of illness:

a) Malignant diseases, tumor diseases, cancer ◻︎yes ◻︎no

exact illness: ................................................ ...................................

b) Diseases of the nervous system, brain and spinal cord ◻︎yes ◻︎no

exact illness: ................................................ ...................................

c) Respiratory diseases ◻︎yes ◻︎no

exact illness: ................................................ ...................................

d) Heart or circulatory diseases ◻︎yes ◻︎no

exact illness: ................................................ ...................................

e) Stomach and intestinal diseases ◻︎yes ◻︎no

exact illness: ................................................ ...................................

f) Diseases of the liver, bile or pancreas ◻︎yes ◻︎no

exact illness: ................................................ ...................................

g) Diseases of the kidney, urinary tract (bladder, urethra) or sexual organs

◻︎yes ◻︎no

exact illness: ................................................ ...................................

h) Metabolic diseases ◻︎yes ◻︎no

exact illness: ................................................ ...................................

i) Skin diseases ◻︎yes ◻︎no

exact illness: ................................................ ...................................

exact illness: ................................................ ...................................

k) Mental suffering ◻︎yes ◻︎no

exact illness: ................................................ ...................................

l) Other illnesses ◻︎yes ◻︎no

g exact illness: ................................................ ......................................

m) Risk factors (HIV, hepatitis, blood clotting disorders) ◻︎yes ◻︎no

exact illness: ................................................ ...................................

n) What else would you like to tell us? (expectations, goals, wishes, etc.)

................................................ ................................................ ..............................

................................................ ................................................ ..............................

................................................ ...................

I hereby confirm that all information is correct and am aware that incorrect information may affect the
effectiveness of the treatment.

................................................ .................................

Signature Date