Locate Us:
2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3049 6500
Fax. 020 3049 6515
Navigation Menu
Close Menu
Home
Services
Compliments & Suggestions
GDPR & PRIVACY NOTICE
GDPR Patient Leaflet PRIVACY NOTICE
Close Menu

Back Pain Online Consultation

Please fill out the form below, and one of our doctors will contact you regarding the consultation:

Patient Information

Name: *
Date Of Birth: *
NHS Number (if known):
Address:
Postcode:
Contact Number: *
E-Mail Address: *

Consultation Information

1. Have you read information about your symptoms on Patient.info?

    It is advised that you read up about this condition and the related symptoms.

    Yes

    No

    2. Have you injured your back?

      Yes

      No

      3. Do you currently have back pain?

        Yes

        No

        4. Would you describe your back pain as upper or lower back?

          5. How would you rate your back pain on a scale of 1-10 (1 being the least painful and 10 being the most painful)?

            6. Please describe your symptoms:

              7. How long have you had these current back symptoms?

                8. Does your back pain wake you up in the night?

                  Yes

                  No

                  9. Are you able to walk without assistance?

                    Yes

                    No

                    10. Are you confined to bed as a result of your back pain?

                      Yes

                      No

                      11. Have you been diagnosed with a back problem by a doctor?

                        Yes

                        No

                        12. Does your back pain go down one leg?

                          Yes

                          No

                          13. Does your back pain go down both legs?

                            Yes

                            No

                            14. Do you have loss of bladder control?

                              Yes

                              No

                              15. Do you have difficulty passing urine?

                                Yes

                                No

                                16. Do you have loss of bowel control?

                                  Yes

                                  No

                                  17. Do you have any numbness around your anus or behind the genitalia?

                                    Yes

                                    No

                                    18. Have you had any unexplained weight loss recently?

                                      Yes

                                      No

                                      19. During this illness have you had a fever?

                                        Yes

                                        No

                                        20. Have you had any operations on your back?

                                          Yes

                                          No

                                          21. Have you had any previous fractures (break) of the spine?

                                            Yes

                                            No

                                            22. Have you ever been diagnosed with osteoporosis?

                                              Yes

                                              No

                                              23. Have you ever had prostate, bladder, breast, thyroid or lung cancer?

                                                Yes

                                                No

                                                24. Have you had any investigations relating to this condition?

                                                  Yes

                                                  No

                                                  25. Is there anything else you would like to tell us that has not been asked in the previous questions?

                                                    26. Do all of the following apply to you?

                                                    • I will read the patient information leaflet supplied with my medication.
                                                    • The medication is for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)
                                                    The conditions must apply for you to be able to use this service.

                                                    Yes

                                                    No