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Dokar online consultations Eng
Please fill out the form to develop a personal low back rehabilitation program
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* Indicates required question
Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
City, Country
*
Your answer
e-mail
*
Your answer
How to contact you?
*
WhatsApp
Viber
Other:
Number for connection
*
Your answer
Your birthday
*
MM
/
DD
/
YYYY
Your age
*
Your answer
Height
*
Your answer
Wight
*
Your answer
Your officially confirmed diagnosis of lower back disease (if you know)
Your answer
Stage of the disease
*
Acute (less than 7 days)
Subacute (from 7 to 30 days)
Chronic (more than 30 days)
Exacerbation of chronic
Other:
How long have you had low back problems?
*
Less than a week
From 1 week to 1 month
1 month to 6 months
6 months to 1 year
From 1 year to 5 years
Over 5 years
Other:
Indicate the manifestation of the disease
*
Pain
Crunch
Mobility restriction
Other:
Required
Most pronounced symptom
*
Choose
Pain
Crunch
Mobility restriction
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