| QUESTIONERS FOR VOLNTEER'S WORKING DENTIST FOR DOING MRI CERVICAL SPINE TEST: | ||||||
| Do you have any objection to be one of the volunteer for MRI spine test? | ||||||
| Name: |
Gender: M F |
Age: |
Specialty: Dental Student: GDP: Specialist: |
|||
| Type of work: General Specialty of work: Ortho OMF Surgery, Other (Specify please) | ||||||
| Have an oriented assistant: YES NO Not always | ||||||
| Posture during work : Normal Twisted | ||||||
| Accessibility to your instruments Easy Access Difficult Access | ||||||
| How many years you are working in Dentistry: Less than ten years More than ten years | ||||||
| How many days per week you are working 1-2-3-4-6-7 day(s) | ||||||
| How many hours per day you are working (1-5) hours (6-10 )hours | ||||||
| Additional hobbies burden your neck movement Yes No if yes specify please | ||||||
| Pleas answer the following questions: | ||||||
| Question: | Yes | No | Comment | |||
|
Do you have any C/I for taking MRI ,Like
Pregnancy(female), Pacemaker or metal object in your body |
||||||
| Do you smoke | ||||||
| Do you have any family history of cervical spondylosis ? | ||||||
| Do you have any past, present medical problems | ||||||
| Do you take any medication ? | ||||||
| Have you consulted physician before for neck and /or shoulder symptoms ? | ||||||
| Other disease? | ||||||
| Symptoms: | ||||||
|
Do you have any cervical spine symptoms like:
Neck ache or stiffness (could be worse during activity) Weakness and numbness in the arm, hand and orfingers Walk trouble Imbalance Headache Grinding and popping sound/feeling in neck movement Loss of bladder or bowel control(neurological causes only) Dizziness when tilting head back Others |
||||||
| Name | Signature | Date | ||||
| Thank you for your help | ||||||