Medical referral, to Dr Björn Bragée, MD

Stockholm Pain Specialist Clinic,

Banérgatan 23, SE 155-22 Stockholm, SWEDEN

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Name:
Adress:
Postal Code:
City, Country:
Telephone:
E-mail: Please control!
Date of Birth:
Title/Profession:
What kind of pain problems leads to the consultation?:
Who is your ordinary doctor and hospital, and what is your actual pain treatment:

Have you consulted Pain Management specialists before?:

What are your expecations of treatment or outcome?

(Of course you want to have pain relief, but is there any specific wishes?)
How will the payment be arranged, via an insurance (name it) or in other way?

How did you come in touch with the Stockholm Pain Program, recommendation?

 

Which medical investestigations have you undergone (one or more markings!)

None what so ever

Ultrasonic Lab tests Reuma-tests X-ray MR -magnetic resonance tomography

CT computer tomogr. EMG/ENEG (neurophysiology) Pain Clinic

other:

 

Which treatments have been tested (one or more markings!)

None what so ever

Physiotherapy massage Aqua/warm water Relaxation TENS/El. stimulation

Analgetics anti- inflammatory drugs sedatives Morphine/opioides  Acupuncture Feldenkrais Education Psychotherapy

Corticosteroid injections  Neural blocks Surgery (pain surgery)

 

Specify/other:

 

Are you interested to take part in a Pain Program and want to have a planning and preliminary view on costs and do you understand that no medical result can be guaranteed?  (yes or no)

Yes/No