Name

Birth Date

Age

Gender

Male Female

Residency

--< Select >-- Cairo Giza Alexandria Port Said Suez Demiatt Dakahlia Sharkia Qalyoubia Kafr Shaikh Gharbia Menouffia Behaira Ismaillia Beni Suif Fayoum Minia Assuit Sohag Qena Asswan Luxor Al Bahr Al Ahmar Al Wadi Al Gaddid Matrouh N. Sinai S. Sinai Other Country

Occupation

Weight (kg)

Height (m)

BMI (Body Mass Index)

Smoking

Yes No

Informed Consent

Onset

acute subacute insidous

Course

progressive regressive stationary

Pain increase with

sitting walking coughing and straining All

Pain relieved with

forward flexion supine position lumbar extention

Type of pain

burning tingling numbness

Description of pain

sharp dull throbbing

Intensity of pain

Mild (1-2) Moderate (3-6) Severe (7-10)

Time of maximal pain

Morning Night

Side of Cervical radiculopathy

Right arm Left arm Both arms

Side of Lumbar radiculopathy

Right leg Left leg Both legs

Onset of Cervical and Lumbosacral radiculopathies

Simultaneously Cervical pain first Back pain first

Spurling’s test

Positive Negative

Shoulder abduction test

Positive Negative

Axial cervical distraction test

Positive Negative

Straight leg raising test

Positive Negative

Crossed straight leg raising test

Positive Negative

Bowstring test

Positive Negative

Cervical X ray findings

Lumbosacral X ray findings

MRI Cervical spine

MRI Lumbosacral spine

Drug

Dose

Frequency

Pain intensity after 2 weeks follow up

Mild (1-2) Moderate (3-6) Severe (7-10)