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ONZ Datteln - Head Office
Heibeckstrasse 30
45711 Datteln
Tel. 02363 3669 0
Fax. 02363 3669 136
www.onz-online.de
kontakt-da@onz-online.de

ONZ Recklinghausen
Im Elisabeth Krankenhaus
Röntgenstrasse 10
45661 Recklinghausen
Tel. 02361 30238 0
Fax. 02361 30238 138
www.onz-online.de
kontakt-re@onz-online.de

Dr. Thomas Bierstedt -- Dr. Bernd Illerhaus -- Dr. Guido Ostermann
Fachäzte Für Neurochirurgie, Wirbelsäulenchirurgie, Chirotherapie, Akupunktur

Assoc. Prof. Dr. Wolfram Steens -- Dr. Bernard Neuhaus -- Dr. Maximilian Timpte
Facharzte für Orthopädie und Unfallchirurgie, Spezielle Orthopädische Chirurgie, Chirotherapie, Sportmedizin Physikalische Therapie, Osteologie, Akupunktur, H - Ärzte

Elisabeth Krankenhaus -- Röntgenstrasse 10 -- 45661 Recklinghausen -- Tel.: +49 2361 30238212

Malte Peterson -- Head of International Department -- Tel.: +49 171 3000088

Personal Information

Name (First Middle Last) :

Date of Birth (i.e. Jan 10, 1968) :

Gender :

Male

Female

Height (indicate cms or inches) :

Weight (indicate kgs or lbs) :

Box/Street # :

City/Town & State/Province :

Zip/Postal Code & Country :

Home / Cell Phone :

E-mail :

Additional E-mails :

Pain Synopsis

When did your pain symptoms start?

Have the pain symptoms changed within the past 6-12 months?

Yes

If YES, are the better or worse?

Describe where the pain starts and radiates to :

What makes the pain worse?

Describe any numbness, tingling, neurodeficits, weakness, etc. in your leg/foot or arm/hand :

Back / Leg Pain

	N/A	All back pain	More back pain than leg pain	50/50	More leg pain than back pain	All leg pain
Choose one

Back / Leg Pain Levels (0 = no pain - 10 = constant extreme pain)
* When you have the least amount of pain, what number would that be between 0 and 10?
* When you have the most amount of pain, what number would that be between 0 and 10?
* Rate your average pain (i.e. 20 days of the month, you have a Minimum (2) pain, but 10 days of the month you have a Maximum (9) pain, therefore the Average pain may be closer to the Minimum than to the Maximum, giving you an Average of possibly (4))

	N/A	1	2	3	4	5	6	7	8	9	10
Minimum pain
Maximum pain
Average pain

Neck / Arm Pain

	N/A	All neck pain	More neck pain than arm pain	50/50	More arm pain than neck pain	All arm pain
Choose one

Neck / Arm Pain Levels (0 = no pain - 10 = constant extreme pain)
* When you have the least amount of pain, what number would that be between 0 and 10?
* When you have the most amount of pain, what number would that be between 0 and 10?
* Rate your average pain (i.e. 20 days of the month, you have a Minimum (2) pain, but 10 days of the month you have a Maximum (9) pain, therefore the Average pain may be closer to the Minimum than to the Maximum, giving you an Average of possibly (4))

	N/A	1	2	3	4	5	6	7	8	9	10
Minimum pain
Maximum pain
Average pain

Tolerances / Endurance ( maximum time / distance )

Sitting :

Standing :

Walking :

Personal Health Information

Have you had any previous spine surgery? :

Yes

If YES, what year was the surgery? :

If YES, which level(s) of the spine were involved? (e.g. C5-C6, L4-L5) :

If YES, what type of surgery was it? (e.g. fusion, discectomy, laminectomy, artificial disc replacement) :

If YES, were there any complications or revisions needed? :

If YES, was the surgery considered successful? :

Have you had more than one Spine surgery? If yes, please provide details for each. :

Other Previous Surgeries (ie. Hernia surgery done with mesh) :

Allergies of any kind (towards medication, metals, food, etc?) :

Other co-existing health issues :

High blood pressure

Cholesterol

Depression

Diabetes

Heart disease

Pace maker

Asthma

Cancer

Kidney disease

Liver disease

Other :

Indicate each Spine Related medication you are taking :

Indicate All Other medication you are taking :

Case history - work involvement & leisure time activities

The physical strain in job and leisure time plays a major role for orthopedic diagnosis and therapy. This questionnaire will therefore help us to give you a proper evaluation.

What is the occupation you work / previously worked in? :

Have you ever had to stop working or change occupations because of your condition? :

Yes

If YES, when? :

Under which of these conditions are you working? :

Full time

Part time

Not working

What occupation are you working at presently? :

Your present occupation, is it :

Physical work

Non-physical work

Not working

Is your occupation physically straining for you? :

Yes

Not working

Is your occupation associated with monotonous body postures? :

Yes

Not working

Does your pain make it difficult to work? :

Yes

Not working

Do your symptoms allow you to play sports / exercise? :

Yes

If YES, what kind of sports / exercise are you doing? :

If NO, did you do any sports / exercise before? :

Yes

If YES, what kind of sports / exercise did you do? :

Will you have someone to support you at home after surgery? :

Yes

Additional Information not included in previous questions :

Body Scheme

1) Mark the pain area with an X.
2) Draw a line to where the pain radiates to.
3) Draw an arrow at the end of each line to show where the pain stops.

Within 5-10 business days of receiving all your data in Germany, you will receive a diagnosis and evaluation. This may be relayed through your Liaison. Therefore it is important that you stay in communication with your Liaison.

Date :

Signature :

Elisabeth Krankenhaus -- Röntgenstrasse 10 -- 45661 Recklinghausen -- Tel.: +49 2361 30238212

Malte Peterson -- Head of International Department -- Tel.: +49 171 3000088