You can always press Enter⏎ to continue
Fortæl os om din problemstilling.
Udfyld venligst disse få spørgsmål inden du kommer til klinikken.
15
Questions
START
Language
Dansk
English (UK)
1
Fulde navn
*
This field is required.
fornavn
efternavn
Previous
Next
Submit
Press
Enter
2
E-mail
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
3
Telefonnummer
*
This field is required.
Hvor vi kan kontakte dig.
Previous
Next
Submit
Press
Enter
4
CPR-nummer.
*
This field is required.
For at vi kan oprette en journal på dig.
######-####
Previous
Next
Submit
Press
Enter
5
Hvornår startede dit problem?
*
This field is required.
Dato
Dag
Måned
År
Previous
Next
Submit
Press
Enter
6
Hvor har du mest ondt?:
*
This field is required.
Hovedpine
Svimmelhed eller synsforstyrrelser eller kvalme.
Nakke eller skulder smerter.
arm smerter, Snorrende følelse eller kraftnedsættelse i armen.
Brystryg smerter.
Lænd, bækken eller hofte smerter
Ben Smerter, Snorrende følelse eller kraftnedsættelse i benet.
Snurrende følelse
Brændende fornemmelse
Sovende fornemmelse
Udtalt træthed (generelt uoplagt)
Feber
Uforklarligt Vægttab
Andet
Previous
Next
Submit
Press
Enter
7
Tegn din smerte.
Marker hvor det generer dig. Venstre/front & Højre/bag.
Previous
Next
Submit
Press
Enter
8
Tegn din smerte.
Marker hvor det generer dig. Venstre/front & Højre/bag.
Previous
Next
Submit
Press
Enter
9
Fortæl hvad der er sket, hvordan er det opstået?
*
This field is required.
Gerne så mange detaljer som muligt.
TextSize
Created with Sketch.
Huge
Large
Normal
Small
Bold
Created with Sketch.
Italic
Created with Sketch.
Underline
Created with Sketch.
Underline Copy
Created with Sketch.
Ok
NumberList Copy 2
Created with Sketch.
quote
Created with Sketch.
Break
Created with Sketch.
Image
Created with Sketch.
Ok
Smiley
Created with Sketch.
Previous
Next
Submit
Press
Enter
10
*
This field is required.
Hvor ondt har du lige nu? Skub markøren til et tal mellem 1-10 (10 er værst mulige)
Previous
Next
Submit
Press
Enter
11
Hvor stærke er dine smerter? På en skala fra 1-10?
*
This field is required.
Evt. også uddybende forklaringer.
TextSize
Created with Sketch.
Huge
Large
Normal
Small
Bold
Created with Sketch.
Italic
Created with Sketch.
Underline
Created with Sketch.
Underline Copy
Created with Sketch.
Ok
NumberList Copy 2
Created with Sketch.
quote
Created with Sketch.
Break
Created with Sketch.
Image
Created with Sketch.
Ok
Smiley
Created with Sketch.
Previous
Next
Submit
Press
Enter
12
Hvad provokerer dine smerter? Hvordan?
*
This field is required.
Gerne så mange detaljer som muligt.
TextSize
Created with Sketch.
Huge
Large
Normal
Small
Bold
Created with Sketch.
Italic
Created with Sketch.
Underline
Created with Sketch.
Underline Copy
Created with Sketch.
Ok
NumberList Copy 2
Created with Sketch.
quote
Created with Sketch.
Break
Created with Sketch.
Image
Created with Sketch.
Ok
Smiley
Created with Sketch.
Previous
Next
Submit
Press
Enter
13
Hvad kan du gøre for at lindre smerterne? Hvordan?
*
This field is required.
Gerne så mange detaljer som muligt.
TextSize
Created with Sketch.
Huge
Large
Normal
Small
Bold
Created with Sketch.
Italic
Created with Sketch.
Underline
Created with Sketch.
Underline Copy
Created with Sketch.
Ok
NumberList Copy 2
Created with Sketch.
quote
Created with Sketch.
Break
Created with Sketch.
Image
Created with Sketch.
Ok
Smiley
Created with Sketch.
Previous
Next
Submit
Press
Enter
14
Har du tidligere været indlagt eller opereret? Tager du medicin?
Det er dit ansvar at vi får al medicin med.
TextSize
Created with Sketch.
Huge
Large
Normal
Small
Bold
Created with Sketch.
Italic
Created with Sketch.
Underline
Created with Sketch.
Underline Copy
Created with Sketch.
Ok
NumberList Copy 2
Created with Sketch.
quote
Created with Sketch.
Break
Created with Sketch.
Image
Created with Sketch.
Ok
Smiley
Created with Sketch.
Previous
Next
Submit
Press
Enter
15
Har du nuværende eller tidligere alvorlige sygdomme?
Det er dit ansvar at vi får al medicin med.
TextSize
Created with Sketch.
Huge
Large
Normal
Small
Bold
Created with Sketch.
Italic
Created with Sketch.
Underline
Created with Sketch.
Underline Copy
Created with Sketch.
Ok
NumberList Copy 2
Created with Sketch.
quote
Created with Sketch.
Break
Created with Sketch.
Image
Created with Sketch.
Ok
Smiley
Created with Sketch.
Previous
Next
Submit
Press
Enter
16
Har du været undersøgt ved andre? f.eks. lægen eller fysioterapeut.
*
This field is required.
Ja
Nej
Previous
Next
Submit
Press
Enter
17
Har du oplevet denne problemstilling tidligere?.
*
This field is required.
Ja
Nej
Previous
Next
Submit
Press
Enter
18
Marker dine symptomer:
*
This field is required.
Hovedpine
Synsforstyrrelser
Svimmelhed
kvalme eller opkast
Ømhed
Stivhed
Skarpe jag ved visse bevægelser
Snurrende følelse
Brændende fornemmelse
Sovende fornemmelse
Udtalt træthed (generelt uoplagt)
Feber, hoste eller forkølelse.
Uforklarligt Vægttab
Previous
Next
Submit
Press
Enter
19
Underskrift
*
This field is required.
Dette gør du med din mus eller finger på skærmen, hvis den et trykfølsom.
Clear
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
19
See All
Go Back
Submit