The Luklinski Back Pain Clinic
2, Milford House, (off Harley St.) 7, Queen Anne St, 
Tel: 0207-631-3067 Emergencies: 0410-901140
www.back-pain.co.uk

Consultation Form

Contact Us!
Please read the FAQ before contacting us

The results of the diagnosis will be emailed to you within a few days depending on our patient work load at the clinic. We may need to contact you by email for further information. Please note this service is free and in the absence of a physical examination our response cannot be relied upon to determine your true condition.


NAME    EMAIL
(Ensure that your email address is valid!)

Age Height  Weight

QUESTIONS ABOUT YOUR PAIN
Where is your pain?  Neck Middle  back  Lower Back
On which side is the pain? Left Right Middle
Any pain elsewhere? Leg Arm   Back
When did the pain start? Recent   1wk + 1mth +
Do you have pain only? only pain with stiffness
What brings the most relief? Rest Movement Sitting 
Lying down on the left side      Lying down on the right side
Do you have any night pain? Yes No
Do you have any morning pain? Yes No
Which makes the pain worse? Bending forward Bending backward 
Turning left   Turning right   Leaning left Leaning right
Walking on a flat surface   Climbing stairs  None of these 
What action causes more pain?
Do you have numbness or tingling (pins & needles) No
Describe your pain:

GENERAL QUESTIONS
1  Any muscular weakness? Yes No 
2  Can you get up from sitting? Yes No 
3  Have any scans been obtained? Yes No 
4  Have you taken anabolic steroids? Yes No 
5  Do you suffer from vertigo? Yes No 
6  Any headaches? Yes No 
7  Any weight loss recently? Yes No 
8  Any urinal or bowel problems? Yes No 
9  Are you taking medication? Yes No 
10 Have you been examined? Yes No 
11 Surgery advised? Yes No 
12 Would you consider surgery? Yes No 
How is your condition generally during the day?

Evening   Midday     Afternoon 

Since the problem started are you:  Better   Worse   No change
What practitioner have you seen?
What diagnosis have you been given?   Please describe in the Information Box.
What treatment have you received for your condition? Please describe in the Information Box.

Information Box
Please provide any additional information or queries you may have.
If you live in the UK you may wish to call us: 0207-631-3067

        Please provide a telephone number: