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About
About Clinic
Team
Dr Sambhav Shah
Conditions
Back Pain
Cervical Fixations
Sciatica
Spinal Fracture
Slipped Disc
Stenosis
Spondylosis
Spondylolisthesis
Non Surgical Care
Physiotherapy
Spinal Injections
Epidural
Strength Training
Electrical Muscle Stimulation
Surgical Treatments
Spinal Fusion
Spinal Reconstruction
kyphosis
Scoliosis
Vertebroplasty
ACDF
ALIF
Disc Replacement
OLIF Fusion
KLIF Fusion
Cervical Laminectomy
Minimally Invasive Treatment
Minimally Invasive
TLIF
Laser Spine Surgery
Endoscopic
Endoscopic Discectomy
Endoscopic Decompression
Aqua Therapy
Media
Contact Us
sambhav@spinesecure.com
Whatsapp
Back
Home
About
About Clinic
Team
Dr Sambhav Shah
Conditions
Back Pain
Cervical Fixations
Sciatica
Spinal Fracture
Slipped Disc
Stenosis
Spondylosis
Spondylolisthesis
Non Surgical Care
Physiotherapy
Spinal Injections
Epidural
Strength Training
Electrical Muscle Stimulation
Surgical Treatments
Spinal Fusion
Spinal Reconstruction
kyphosis
Scoliosis
Vertebroplasty
ACDF
ALIF
Disc Replacement
OLIF Fusion
KLIF Fusion
Cervical Laminectomy
Minimally Invasive Treatment
Minimally Invasive
TLIF
Laser Spine Surgery
Endoscopic
Endoscopic Discectomy
Endoscopic Decompression
Aqua Therapy
Media
Contact Us
Symptom Assesment
Form
CERVICAL SPINE
THORACIC SPINE
LUMBAR SPINE
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Age
Gender
Male
Female
Other
Symptoms
Please Select
Symptoms
Pain in neck
Pain in arms
Swelling
Stiffness
clumsiness in hands
tingling or numbness
Others
Since
Symptom Intensity
Increase in Intensity Since
Symptom Elaboration
Please Select
Symptom Elaboration
Confined to Back of Neck
Confined to Lower Neck
Radiating to One Arm/Hand
Radiating to Both Arms/Hands
Headache
Difficulty in Walking
Difficulty in Holding Objects
Change in Handwriting
Weakness in the arms or legs
Weakness in Grip for Example, Buttoning shirt
Swelling around the neck
History of Fever/Weight Loss/ Loss of Appetite
Morning Stiffness
Stiffness in Other Joints
History of Trauma
History of Fall
Bowel / Urine Retention
Others
Intensity Increases on
Please Select
Intensity Increases on
Neck Movements
Lifting Weights
Daily Activities
Others
None Of The Above
Relief With
Please Select
Relief with
Medication
Topical application
Rest
None Of The Above
Others
Submit
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Age
Gender
Male
Female
Other
Symptoms
Please Select
Pain
Swelling
Stiffness History of Trauma
Deformity ( Change is spine curvature)
Prominence of Back
Instability in Walking
Weakness in Legs
Others
Since
Symptom Intensity
Increase in Intensity since
Symptom Elaboration
Please Select
Symptom Elaboration
Confined to Back
radiating to one Limb
radiating to both Limbs
Headache
Bowel / Urine Retention
Instability in walking
Weakness in legs
History of Fever/Weight Loss/ Loss of Appetite
Morning Stiffness
Stiffness in other joints
History of Trauma
History of Fall
Bowel / Urine Retention
Others
Intensity increases on
Please Select
Intensity increases on
Walking
Sitting
Sleeping
Standing
Back Movements
Lifting Weights
Daily Activities
None of the above
Others
Relief with
Please Select
Medication
Topical application
Rest
None of the above
Others
Submit
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Age
Gender
Male
Female
Other
Symptoms
Please Select
Pain in lower back or buttocks
Swelling
Stiffness
Leg Pain
Deformity
Weakness in Legs
Others
Since
Symptom Intensity
Increase in Intensity since
Symptom Elaboration
Please Select
Confined to Back
Radiating to one leg
Radiating to both legs
Bowel/Urine Retention
No control in passing Urine/Stool
Tingling, numbness, burning or electric current in the legs
Weakness in legs
Inability to grip footwear
History of trauma
History of Fever/Weight Loss/ Loss of Appetite
Morning Stiffness
Intensity increases on
Please Select
With Back movements
Lifting weights
Daily Activities
Walking
Standing
Sitting
Sleeping
None of the above
Others
Relief with
Please Select
Medication
Topical application
Rest
None of the above
Others
Submit
