Intake

Name*

Official name on eID

First name*

Official first name on eID

Date of birth*

Gender*

Female

Male

National registry number*

Back of eID card

Email address*

When did you first experience the pain ?*

In what year or at what specific date ?

Describe your pain and specify the areas where you feel it*

How did the pain start ?*

Describe the progression

When do you experience most of your pain ?*

Multiple answers are possible

In the morning

In the afternoon

In the evening

Overnight

How could you best describe your pain? What kind of pain do you experience?*

Multiple answers are possible

Drilling

Squeezingv

Pulling

Stabbing

Beating

Burning

Itching

Sharp

Dull

Throbbing

Pressing

Stiffness

Describe your pain in terms of your emotional perception*

Multiple answers are possible

Exhausting

Depressing

Worrying

Annoying

Distressing

Is the pain…*

Deep

Superficial

Rate your pain today ranging from 0 (no pain) to 10 (the worst pain)*

0 - 3

4 - 6

7 - 8

> 8

Rate your average pain during the day ranging from 0 (no pain) to 10 (the worst pain)*

0 - 3

4 - 6

7 - 8

> 8

Rate your average pain during the night ranging from 0 (no pain) to 10 (the worst pain)*

0 - 3

4 - 6

7 - 8

> 8

What increases your pain?*

Walking

Sitting

Standing

Lying down

Lifting

To do sports

Sexual activity

Cold

Heat

Other

What relieves your pain?*

Walking

Sitting

Standing

Lying down

Lifting

To do sports

Sexual activity

Cold

Heat

Other

What additional pain do you experience?*

None

Headaches

Vertigo

Tingling sensation

Loss of strength

Sudden incontinence

Depressive symptoms

Anxiety

Other

Do you have sleep issues?*

None

Trouble falling asleep

Troubles with sleep continuity

Does your pain affect your mood?*

Yes

Does your pain create tension in your environment?*

Yes

Have you already been treated in a pain clinic?*

Yes

What treatment did you receive?

Have you already consulted a specialist?*

Yes

What kind of specialist?

Have you already seen a physiotherapist?*

Yes

What type of treatment did you receive ?

Massage

Heat

Active rehabilitation exercises

Stretching

Mobilisation/ manipulation

Relaxation exercices

Other

Have you had an injury or an accident in the past?*

Yes (fall, accident, ...)

Describe the injury of the accident and mention in what year it took place

Do you have other health issues?*

Yes

Which ones (high blood pressure, diabetes, heart problems, stomach issues…)?

Do you have any allergies?*

Yes

Which ones?

Have you had an adverse reaction to any medication in the past?*

Yes

Which one?

Do you smoke?*

Yes

Are you an ex-smoker ?

Do you consume alcohol?*

Yes > 1 glas/day

What is your favorite sleeping position?*

What type of sleep mattress do you have?*

Is your sleep mattress more than 10 years old?*

Yes

Medication. What pain medication do you currently take ?*

What blood thinner(s) do you currently take?*

Do you take any other medications? (Blood pressure, cholesterol, diabetes, thyroid,…)*

When did your last radiological examination take place ? (X-ray, CT-scan, MRI…)*

Provide the code for reference

What is the name of your doctor (general practitioner)?

Who referred you to Curendis?*

What are your expectations from Curendis ?*

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Privacy*

I agree to the privacy policy of Curendis.*

By Clicking on ‘SEND’ you agree with the processing of your data within Curendis by our doctors/chiropractors

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