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Dr. Waeil
Dr. Waeil
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Sudan Cupping Test
sudan-cupping test is the first registered dry cupping test in the world
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Personal Information
Name
*
Age
*
Profession
Mobile
*
(xxx-xxx-xxxx)
Address
Email
*
Gender
*
Male
Female
Diabetes/last result
Yes
Heartburn
Yes
Allergies
Yes
Reflux
Yes
Gases/Bloating
Yes
Ulcer
Yes
High blood pressure
Yes
Bronchial asthma
Yes
Constipation
Orthopedic or neurosurgical surgery?
Yes
No
Family member with cervical or spinal problems ?
Father
Mother
Brother
Sister
Cousin
Aunt
From how long are the first symptoms ?
When was the last time you had pain?
Cause for complaint ?
Fall
Lifting heavy
Crash
Other
COMPLAINTS FOR UPPER BODY:
Cervical spine pain?
Yes
No
Pain in the muscles of the shoulder girdle?
Right
Left
Shoulder pain?
Right
Left
Wrists pain?
Right
Left
Pain from the shoulder to the elbow?
Right
Left
Numbness of the palms?
Right
Left
Stiffness/cramps of the fingers?
Right
Left
Warm sensation on palms?
Right
Left
Heels pain?
Right
Left
Feeling of tiredness / weakness of the fingers during work?
Right
Left
Dizziness?
Yes
No
Neck muscles pain?
Right
Left
Tightness in the chest?
Right
Left
Elbow pain?
Right
Left
Pain in the joints of the fingers?
Right
Left
Pain from elbow to wrist?
Right
Left
Swelling of the fingers?
Right
Left
Cold sensation on palms?
Yes
No
Sensation of passing current through hands?
Right
Left
Tailbone pain?
Yes
No
Headaches?
Right
Left
Middle back pain?
Yes
No
COMPLAINTS FOR LOWER BODY:
Warm sensation on feet?
Yes
No
Numbness of the leg?
Yes
No
Pain in the toes ?
Right
Left
Ankles pain ?
Right
Left
Tightness at leg muscles ?
Right
Left
Tightness in the thigh muscles ?
Right
Left
Painful cramping of the feet?
Right
Left
Painful cramps in the muscles of the thigh?
Right
Left
Hip pain?
Right
Left
Groin pain?
Right
Left
Knee pain?
Right
Left
Swelling in the ankle joint ?
Right
Left
Sensation of heaviness in the legs when walking?
Yes
No
Sensation of passing current through feet?
Right
Left
Numbness of the feet?
Right
Left
Numbness of the thigh?
Yes
No
Pain in the foot ?
Right
Left
Pain at leg muscles?
Right
Left
Pain in the thigh muscles ?
Right
Left
Painful cramps of toes?
Right
Left
Painful cramping in the calf muscles?
Right
Left
Back pain ?
Right
Left
Middle
Buttock Pain?
Right
Left
Pain in the lower abdomen ?
Yes
No
Swelling in the feet?
Right
Left
Swelling in the knee?
Right
Left
Sensation of weekness in the legs while walking?
Yes
No
Feeling of localized burning sensation at
Back
Knee
Leg
Thai
When is pain increase?
Getting up
Sitting down
Standing
Beggining of the day
End of the day
Walking
Bedtime
During sleep do not let me sleep/
When is pain reduses?
Getting up
Sitting down
Standing
Beggining of the day
End of the day
Walking
Bedtime
During sleep do not let me sleep/
All of the above
What is the impact of the use of pain relievers tablets?
Week
Good
Very good
I do not use
Have you done?
X-ray
Yes
No
CT-scan
Yes
No
MRI
Yes
No