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Deformity correction
Foot Surgery
Hand Surgery
Hip Surgery
Knee Surgery
Manual Medicine
Neurology
Paediatric Orthopaedics
Rheumatology and Rehabilitation
Shoulder and Elbow Surgery
Spine Surgery
Sports Medicine
Dear Patients,
For the best advice and referral, we recommend that you contact us first by telephone on +41 44 385 74 53 before registering yourself for an appointment.
Thank you.
Your Sports Medicine Team
Hand
left
right
Both sides
Finger
Thumb
Index finger
Middle finger
Ring finger
Pinky finger
Elbow
left
right
Both sides
Shoulder
left
right
Both sides
Elbow
left
right
Both sides
Foot
left
right
Both sides
Hip
Hip, left
Hip, right
Hip, both sides
Knee
Knee, left
Knee, right
Knee, both sides
Dear Patients,
thank you for registering for the assessment and treatment of your back pain. We will forward your inquiry to qualified spinal specialists (in the neurosurgery, orthopedics, neurology, rheumatology or manual medicine departments) and kindly ask you to complete the questions as fully as you can. You will be contacted as soon as possible by the respective department.
If medication is no longer alleviating your symptoms, please call the emergency hotline directly on +41 44 385 72 72.
Thank you
Your Spine Team
Spine localization
Cervical spine
Thoracic spine
Lumbar spine
Coccyx
Cervical spine
right
left
center
Thoracic spine
right
left
center
Lumbar spine
right
left
center
Specific symptoms
Headache right
Headache left
Neck pain right
Neck pain left
Radiance/tingling/pain in the arm right
Radiance/tingling/pain in the arm left
Weakness in arm/hand right
Weakness in arm/hand left
Buttock and/or hip pain right
Buttock and/or hip pain left
Radiance/tingling/pain in the leg right
Radiance/tingling/pain in the leg left
Weakness in the leg/foot right
Weakness in the leg/foot left
Unintentional loss of urine and/or stool
None
How long have you had your symptoms?
0 - 3 months
3 - 12 months
more that 12 months
Have you already been to a doctor/ family doctor because of your symptoms?
Yes
No
Which doctor did you see? (Name, address)
Have you already received surgical treatment for your symptoms?
Yes
No
In which year and where did you receive surgical treatment?
Existing imaging
X-ray
MRI
CT/SPECT CT
Other
Date X-ray
Place X-ray
Date MRI
Place MRI
Date CT/SPECT CT
Place CT/SPECT CT
Date Other
Place Other
Remarks
i
Please describe your condition in as much detail as possible:
How long have you had this condition?
Have you had an accident?
yes
no
Have you already seen a doctor due to this condition?
yes
no
If yes, which preliminary examinations have already been carried out?
If yes, which preliminary examinations have already been carried out?
X-ray
Date
MRI / CT
Date
Neurological examination
Date
Rheumatological clarification
Date
Have you already had an operation due to this condition?
yes
no
If so, which operations have already been performed?
Leave this field blank