Name and surname(mandatory)
Your e-mail (mandatory)
Your subject
Have you been in pain for 3 or more months? YESNO
Is pain perceived in most of your body? YESNO
In which part of the body do you feel persistent pain? Head and faceNeck and armBackBack and leg/sONLY arm or legAbdominal and/or pelvic area painSomething else Explain if something else:
How severe is your pain from 0 to 10? 012345678910
Have you been diagnosed yet?If so, provide brief details below
Do you have any documents or instrumental investigations (e.g. MRI) that you can bring to the consultation? If so, which ones?
Do you take medication for your pain? YESNO
If you take pain medication, please give brief details below:
Have you already received interventional treatments for your pain (e.g. infiltrations, ozone, radiofrequency)? YESNO
If you have already received interventional treatment for your pain (e.g. ozone infiltration, radiofrequency) please give brief details below:
