Mid Back Complaints
Today’s Date: _____/_____/_____ Name:_________________________________________________ Circle the areas on your body where you feel the described sensations, and mark with the appropriate letter(s).
For Office Use Only:
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Quality 1.) Reports Weakness left arm
EXPLAIN_________________________________________
Weakness right leg Sexual dysfunction __________________________________________
Weakness both arms Weakness both legs
__________________________________________
EXPLAIN_________________________________________
__________________________________________
__________________________________________
3.) Overall Status Describe how your pain has changed recently. No change Feels better Feels worse Requiring more medication 4.) Is this a similar or recurrent problem? Deny previous episodes Recurrent problem for ___________________ Similar to previous___________________ 5.) Please circle the number which best describes your pain level, or if the pain varies, list a range (0-No Pain and 10-Worst Pain):
0 1 2 3 4 5 6 7 8 9 10 or Range:________________________________________________________________________
Name:_____________________________________ Date:_______________________
SCC - Mid Back Rib Chest Complaints/revised 08/12vy
Duration 7.) How long have you had this current episode or symptoms? ________________________________________________________
How did it begin? _________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Timing 8.) What activities or positions RELIEVE or DECREASE your pain? Nothing
Bending Neck Backward Heating Pad
Bending Neck Forward Cold Packs
Other, describe:________________________________________________________________________________________
9.) What activities or positions INCREASE your pain? Nothing
Bending Neck Backward Extreme of Motion Lifting
Bending Neck Forward Cold Packs
Other_________________________________________________________________________________________________
Previous Treatment 10.) Which of these treatments have improved your condition?
Chiropractic TENS/e-stim Exercise
Steroid Meds Musc.Relaxers Neurontin, Lyrica Epidural Injection
Other_________________________________________________________________________________________________
11.) Which of these treatments did not improve your condition?
Chiropractic TENS/e-stim Exercise
Steroid Meds Musc.Relaxers Neurontin, Lyrica Epidural Injection
Other_________________________________________________________________________________________________
12.) Which of these treatments are you currently receiving?
Chiropractic TENS/e-stim Exercise
Steroid Meds Musc.Relaxers Neurontin, Lyrica Epidural Injection
Other_________________________________________________________________________________________________
13.) Who were you previously treated by?
Neurosurgeon____________________________ Neurologist_______________________________
Orthopedic Surgeon_______________________ Chiropractor______________________________
Pain Clinic ________________________________________________ Other____________________________________
When was your most recent MRI, CT, or XRAY of problem area?___________________________________________________ Where was it performed?____________________________________________________________________________________
Office use only: Which of these treatments have not been attempted or prescribed?
Chiropractic TENS/e-stim Exercise
Steroid Meds Musc.Relaxers Neurontin, Lyrica Epidural Injection
Other_________________________________________________________________________________________________
SCC - Mid Back Rib Chest Complaints/revised 08/12vy
Safety of Celecoxib vs Other Nonsteroidal Dohme for rofecoxib and of the advisory board of Pfizer/Searle for celecoxib. Dr Anti-inflammatory Drugs Ko¨hler and Dr Kuipers have received travel grants from MSD Sharp & Dohme andfrom Pfizer/Searle. 1. Silverstein FE, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib To the Editor: The results of the Celecoxib Long-
Examen VWO Dit examen bestaat uit 41 vragen. Voor dit examen zijn maximaal 48 punten te behalen. Voor elk vraagnummer staat hoeveel punten met een goed antwoord behaald kunnen worden. Geef niet meer antwoorden (zinnen, redenen, voorbeelden e.d.) dan er worden gevraagd. Als er bijvoorbeeld één zin wordt gevraagd en je antwoordt met meer dan één zin, dan wordt alleen de eerste zin in de beoo