Medical History Questionnaire

Name: First name: Date of birth:

Check-in Date:

Dear patient, dear parents,

Please fill in this questionnaire completely and carefully and send it back as soon as possible before
arrival. Thank you for your support.

The scoliosis was first diagnosed at the age of years.

Menstruation not yet at the age of years cannot remember

Voice break not yet at the age of years cannot remember
Menopause not yet at the age of years cannot remember

Diagnostic of the spine: (Please bring clinical findings and/or X-rays!)

X-ray diagnostics no yes if yes, when last:

MRT/CT no yes if yes, when last:

Previous therapies no
Schroth physical therapy with with good moderate no success
other therapies :
with good moderate no success

Brace therapy no brace until now

yes

First brace, when: current brace since :

Brace wear time: actual recommended: hours/day
Brace company:
not anymore worn from: to

Shoe lift: no left cm right cm

Other aids:
(eg. insoles etc.) no glasses contact lenses hearing aid

ASKLEPIOS KATHARINA-SCHROTH-KLINIK  Korczakstr. 2  55566 Bad Sobernheim 1/3

Phone: 0049 - 67 51 / 8 74 - 0  Fax: 0049 - 67 51 / 8 74 – 170
07.09.2016
Long-term medication no

Name of the medicine Dose (eg. 50mg) Time of taking

(eg. 1x in the morning, 1x in the
evening)

On-demand medication (in case of pain, asthma attack or sleeping problems)

Name of the medicine Dose (eg. 50mg)

Spinal surgery: no
yes when: where:

Allergies/intolerances: no yes Please bring your allergy passport to the rehabilitation!

Which:
Drug allergy:
Food intolerances no yes
Which:
Vaccinations took place regularly: no yes Please bring your vaccination certificate to the rehabilitation!
(only relevant for children and teenagers)

Rehabilitation aims
Pain relief
Correcting posture
Correcting spine curvature
Strengthening of back muscles
Improving performance
Improving mobility
Learning Schroth exercises
Refreshing Schroth exercises
Preventing progression of curvature
Getting a guidance how to do exercise at home
Exchange of experience with other patients
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 Learning strategies to deal with this disease (information and training)
Increasing motivation
Prolonging brace wearing time
Adapting to brace compliance
Avoiding surgery
Others:

Domestic situation (from patient‘s point of view)

concerning adults:
single life partnership divorced
married living apart widowed

children: no yes number: still living at home

number: economically independent

Concerning children and teenagers:

siblings: no yes number: still living at home

number: economically independent

Address of the closest relatives or the parents in case of children

Name:
Address:

Email:

Phone number: during the day:

in the evening:
mobile:

Any further remarks:

City, date Signature patient/parent

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