|
Duration of neck pain
|
Do you have decreased balance with walking?
|
|
Do you have difficulty buttoning your shirt?
|
|
|
Do you have right upper extremity radiating pain
|
If yes, specify areas
• • •
|
|
If yes, intensity
• • •
|
|
|
Do you have left upper extremity radiating pain
|
If yes, specify areas
• • •
|
|
If yes, intensity
• • •
|
|
|
Do you have neck pain?
|
If yes, intensity
• • •
|
|
Right upper extremity numbness and tingling?
|
If yes, specify areas
• • •
|
|
If yes, intensity
• • •
|
|
|
Left upper extremity numbness and tingling?
|
If yes, specify areas
• • •
|
|
If yes, intensity
• • •
|
|
|
Do you have bladder disfunction?
|
Do you have bowel disfunction?
|
|
Lumbar condition treatment
• • •
|
If epidural injection was selected, how many
|
