Please fill the questionnaire to see whether you are a suitable candidate for this Back Care program
Please tick all the squares applicable. A feedback will be given in two working days.
Where in your spine do you feel pain?
Neck (cervical spine)
Mid or Upper Back (thoracic)
Low Back (lumbar or sacral)
Approximately, how long have you been experiencing low back pain?
Less than 6 weeks
6-12 weeks
More than 12 weeks
Is this a new pain, a flare-up of existing pain, or episodic
This is a new pain
This is a flare-up
Episodic
Do you have a persistent fever (100.4 degrees or higher) or unexplained weight loss?
Yes
No
Your sleep is reduced in the past 4 weeks due to pain?
Yes
No
How would you rate your pain (on average) on a scale from 0 to 10, with 0 no pain and 10 being unbearable pain? (worst pain experienced in your life like labor pain in ladies is equivalent to 10)
0
1
2
3
4
5
6
7
8
9
10
Are you experiencing a loss of bowel or bladder control (retention or incontinence) related to your back pain or injury?
Yes
No
Does your low back pain extend (radiate) down your leg?
Yes
No
Can you tolerate your symptoms and perform most daily activities?
Yes
No
What type of health care professionals have you seen for diagnosis and treatment of your neck or back pain? (Please select all that apply.)
General/Family Practitioner/Internist
Orthopaedic Surgeon
Physical Medicine specialist
Neurologist
Neurosurgeon
Ayurvedic treatment
Homeopath
Physiotherapist
Chiropractor
Pain Management Specialist
Rheumatologist
Oncologist
General Surgeon
Other
Has a healthcare professional told you that any of the following conditions are causing your neck or back pain ?(Please select all that apply.)
Spondylitis (Degenerative Disc Disease in old age)
Disc Prolapse (Herniated Disc)
Sciatica (Pulled nerve in the leg)
Spondylolisthesis
Traumatic Vertebral Fracture
Vertebral Compression Fracture
Spinal Stenosis
Severe Osteoporosis (Lack of Calcium/ very fragile spine)
Bone Spur (Osteophytosis)
Failed Back Syndrome
Tumor or infections like Tuberculosis/ Osteomyelitis
Other
Don't have a diagnosis or don't know
Has a medical doctor diagnosed you with any of the following conditions?
Depression
Anxiety disorder
Not applicable
How are you and your doctor currently treating your neck or back pain? (Please select all that apply.)
Anti-inflammatory medications (such as ibuprofen, Diclofenac sodium Celecoxib, Piroxicam etc)
Acetaminophen (Paracetamol)
Doctor-prescribed pain medications (such as Tramadol, Alprazolam, codeine, hydrocodone, oxycodone, or Dextro-propoxyphene)
Herbal (Ayurvedic)
Nutritional supplements, such as Glucosamine, chondroitin, vitamins
Physiotherapy
Chiropractic therapy
Surgery has been done without a metal plate fixed
Surgery has been done with a metal plate inside.
How would you rate the effectiveness of your current neck or back pain treatment? (Please select all that apply.)
My medication and treatments are very effective
My current treatment relieves my pain sometimes, but not all of the time
My current treatment is no longer effective
No treatment has been effective for my pain
MRI of the Spine has been done
Yes
No
If answer is Yes, please write the final conclusion below
E-APPOINTMENT
You can make a provisional appointment for consultation between 9 AM to 1 PM on all days except Saturdays and between 4.30 and 7 PM on Mondays, Wednesdays and Fridays. Appointment is not confirmatory unless the consultation fee of 250 Rs is paid in advance as DD C/O Kumar centre, Kochi 32, The Federal Bank Vyttila or cash paid at the centre.
Those who wish to get admitted directly for treatment may contact the centre over phone to check the availability of room and suitability for treatment.
Where in your spine do you feel pain? 