Name Email Address Tel/ Mobil Pain experience description History/ Beginning Specific movements that intensify the pain (onset) Pain Duration < 3 Months > 3 Months > 6 Months > 12 Months > 5 Years Pain type feels like: Muscular (tissue) / Muskulär (Gewebe) Skin, Muscles, Bone, Joints (somatic) / Haut, Muskeln, Knochen, Gelenke (somatisch) Nerve (neuropathic) / Nerven (neropathisch) Organs/ Abdomen (visceral) / Organe/Unterleib (viszeral) When is the worst pain? Morning Afternoon Night Preffered appointment day Monday Tuesday Wednesday Thursday Friday Saturday Preffered appointment time 13-15 15-17 17-19 19-21 Preffered Location Mobile Appointment/ Hausbesuche Praxis Anjali (Charlottenburg) Jetzt & Hier (Mitte) Radiology, diagnostic images, medical reports Pain medication Send *All information collected with this form is kept strictly confidential. Praxis Anjali
