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Today's Date:
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Patient Last Name:
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Patient First Name:
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Patient Date of Birth:
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Which shoulder are you scheduled to be seen for?
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Right
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Left
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Both, if Both:
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Are you right or left handed?
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How long have you had this problem?
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Date of injury, if any
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What were you doing when the injury occurred?
For example: working for employer, working at home, playing sports, riding in vehicle
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How exactly did the injury occur?
For example: fell from a 6' ladder, knee hit the dashboard, fell down stairs
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Other:
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Were you unable to work due to this injury?
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No
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Yes
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If yes, how long?
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Were you unable to do your normal daily routines due to this injury?
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No
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Yes
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If yes, how long?
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What are the activities you are unable to do now that you could before this injury occurred?
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Is your problem work related?
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Have you had the same problem in the past?
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No
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Yes
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How long ago?
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Have you had the same or similar problem in another area of your body?
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No
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Yes
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What activity, if any, could have caused this problem?
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NA
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How many times a day do you take pain medication?
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Is your problem sports related?
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No
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Yes
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What sport?
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Which statement best describes the status of your problem:
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Previous Care
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None
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Orthopedic Surgeon:
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ER or Urgent Care:
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Family Physician:
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Rheumatologist:
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Other:
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to
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Dates of care: from
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Tests that have been performed: (check all that apply)
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Shoulder X-ray on:
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Shoulder CT on:
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EMG/NCV on:
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MRI on:
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Bone Scan on:
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Blood test:
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Shoulder Ultrasound:
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Please bring a copy of the report
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What have you tried for this problem?
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Which one(s) did you find beneficial?
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Symptoms
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Aggravating Factors
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Describe pain: check all that apply
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Does your pain "extend"?
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No
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Yes
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If yes, where to?
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Fingers
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Arm
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Neck
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Forearm
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Hand
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Other
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