Form-eng - Prof. Dr. Barzó Pál

Registration

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Surname

First name

E-mail

Phone number:

Date of birth

Place of birth

Mother’s name

Address

Is the billing address identical to your home address?

Yes No

Billing address

Have you had a neurosurgical examination before?

Yes No

When?

With what kind of disease?

Spine Brain

Have you had neurosurgery interventions before?

Yes No

When?

With what kind of disease?

Spine Brain

When did the current symptoms arise?

Do you feel dizziness?

Yes No

Do you feel uncertainty when walking?

Yes No

Do you have speech disorder?

Yes No

Do you feel weakness in your arms, legs?

Yes No

Do you experience loss of visual field or blurred vision?

Yes No

Do you have nausea? Vomiting?

Yes No

Did you have epileptic seizures?

Yes No

When did the first happen?

How many times?

Did you have loss of consciousness?

Yes No

Do you have headaches?

Yes No

When do you have headaches?

At rest When moving

Does coughing or straining increase the pain?

Yes No

Where do you have the pain?

in the back of the head in the forehead at the temples

Do painkillers relief the pain?

Yes No

Pain is associated with one or more of the following? (you can mark one or more)

The natutre of walking disorders?

I just have trouble walking, I have no pain I have no pain, but after walking a certain distance my legs feel week, I have pain and numbness and I have to stop. I have slow, trouble walking, but I have no pain (I have a broad-based walking). I have slow, trouble walking, I have memory problems, and urgency to urinate.

The facial pain is:

Constant pain No constant pain

The nature of facial pain?

dull pain sharp pain lightning-like pain

Location of the pain?

in the forehead area of the face, around the eyes radiates to the ear radiates to the jaw

The symptoms were preceded by a wrong movement (lifting, physical work, etc.)

Yes No

It started gradually, I don't know the cause.

Yes No

Where is the pain located?

between the shoulder blades below the shoulder blades to the lumbar region

Is the pain accompanied by numbness?

Yes No

The problem was preceded by a wrong movement (lifting, physical work, etc.).

Yes No

It started gradually, I don't know the cause.

Yes No

Besides neck pain, do you have pain in your arms?

Yes No

Which side?

Left Right

Where does the pain radiate?

on the outer surface of the arm in the thumb on the back of the arm in the three middle fingers on the inner surface of the arm in the little finger I have pain in all my fingers

Do you feel numbness in your arm, fingers?

no on the outer surface of the arm in the thumb on the back of the arm in the three middle fingers on the inner surface of the arm in the little finger I feel pain in my hand and all my fingers

Can you raise your arm horizontally above your shoulder?

Yes No

Is your elbow extension weakened?

Yes No

Is your elbow bending weakened?

Yes No

The grip of your hand weakened?

Yes No

When does the pain intensify?

at rest sitting moving your head at every movement

Does the pain radiate to the neck?

Yes No

The problem was preceded by a wrong move (lifting, physical work, etc.).

Yes No

It started gradually, I don't know the cause.

Yes No

In addition to back pain, do you also have pain in your legs?

Yes No

Which side?

Left Right

Where does the pain radiate?

on the back of the thigh, the back of the leg down to the heel on the outer surface of the thigh, the front surface of the leg down to the big toe in the knees and in the front surface of the thigh

Do you feel numbness in your legs?

no on the back of the thigh, the back of the leg down to the heel on the outer surface of the thigh, the front surface of the leg down to the big toe in the knees and on the front surface of the thigh

What distance can you walk without stopping?

Can you walk on tiptoes?

Yes No

Can you walk on heels?

Yes No

Do you feel a weakness in your knees when you walk? (Do you have a feeling that your knee will not hold your body?)

Yes No

Do you have difficulty / urgency to urinate?

Yes No

When does the back/leg pain intensify?

lying in bed sitting while walking anyway

Do you have any other neurosurgical problems?

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RegistrationSuccessful!

Dear patients!

Due to the large number of applications received, we are currently unable to accept your registration.

Thank you for your understanding!

Registration
Successful!