1 Personal Information 2 Medical Condition 3 Medical Files 4 Select Dates 5 Complete Name and Surname:* E-posta:* Please provide your phone number below with the country code:* Your height in cm:* Your weight in kg:* Your date of birth: Where do you experience pain (Select all that apply)?* Spinal Regions Cervical Spine (Neck) Upper Back (Thoracic Spine) Middle Back Lower Back (Lumbar Spine) Upper Extremities Left Shoulder Right Shoulder Left Elbow Right Elbow Left Wrist Right Wrist Left Hand Right Hand Lower Extremities Left Hip Right Hip Left Knee Right Knee Left Ankle Right Ankle Left Foot Right Foot Please describe your pain and symptoms: How would you describe the pain you usually have?* None Very Mild Mild Moderate Severe Have you been limping when walking?* Rarely/Never Sometimes or just at first Often, not just at first Most of the time All of the time For how long are you able to walk before the pain becomes severe? * No pain > 60 minutes 16 to 60 minutes 5 to 15 minutes Around the house only Not at all - severe on walking How long have you had your pain in the hip/knee?* 1-3 months 3-6 months 6-12 months 1-2 years 2+ years What are your functional problems related to your pain complaint? (Select all that apply)* Standing Sitting Kneeling Laying Walking Bending Climbing Stairs Other Do you have any known medical diagnosis? (Select all that apply)* Hypertension Diabetes Asthma Heart Disease Liver Disease Allergy Renal Diseases Neurological Diseases Cancer Infectional Diseases I do not have any other chronic diseases or diagnosis Other Do you have night pain that wakes you up?* Yes No Please describe your condition.* Describe your complaints as a whole story. Please describe your previous treatments, surgeries and medications you use currently.* Please upload your medical files below:* (Only rar and zip files are allowed) Please select dates: We will investigate based on the information you have provided to us and get back to you as soon as possible. Complete the form to receive your second opinion. Phone Whatsapp Previous Next Submit
