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Appointments

Urgent Appointment

Please fill out this form to request a free spine case review. One of our practice members will get back in touch with you soon.

YOUR DETAILS

INSURANCE DETAILS

Insurance Type *:

YOUR CURRENT PROBLEM

How long have you had your current complaint for (click one only)?

Date:

Which area is your MAIN problem?

Back Pain Weakness/Numbness in Arm or Legs Neck Pain Back and Leg Pains Neck and Arm Pains Difficulty Walking Headaches Other

TREATMENTS
Have you had any treatment for your condition:

IMPORTANT INFORMATION : Please Click on either Yes or No.

Do you take any blood thinning medication: Yes No

Do you smoke Cigarettes: Yes No

Do you have Diabetes: Yes No

Have you have surgery on your Spine (Neck or Back) before: Yes No

Have you been diagnosed with cancer before: Yes No

Have you have any problems with Anaesthetics before: Yes No

PLEASE CLICK IF YOU HAVE HAD ANY OF THE FOLLOWING PROBLEMS:

MEDICATIONS: (For each medication—please type in the name, then Click on +Add more for another medication).

Enter Medication here

INVESTIGATIONS:

Please click on any investigations that you have had:

Xrays
CT scan
MRI scan
Nerve conduction study
Bone scan
Spinal Injections
Discogram
Myelogram
Ultrasound
Other

Please attach any reports that you have had: Or please FAX any reports to 02 9650 4902

Have any doctors recommended surgery for your current problem:	Yes No

Some patients who continue to have debilitating pain and limited function, and have exhausted all conservative options (non-surgical) may benefit from surgery. However, surgery does have significant risks. Do you feel that your problem limits your activities enough or causes you enough pain that you would consider surgery?	Yes No

© Dr Santosh Poonnoose Neurosurgeon Spinal Surgery Bedford Park SA
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