"Patient Intake Form - Shoulder Injury"

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Shoulder Form
Name:___________________________________________________
Job description:____________________________________________
Students Only
Employer:_________________________________________________
School:______________________________
Primary Care Provider:_______________________________________
Grade:_______________________________
Who referred you:___________________________________________
Sport:________________________________
Position:_____________________________
Did you have an Injury?
Yes
No
Date of Injury:_______________________
When did your symptoms start:______________________
Place of Injury:______________________
Your symptoms started: (circle)
gradually
suddenly
Explain what happened: ________________________
Explain any details: ________________________________
_____________________________________________
__________________________________________________
_____________________________________________
__________________________________________________
_____________________________________________
__________________________________________________
_____________________________________________
__________________________________________________
_____________________________________________
__________________________________________________
Have you had a problem/Injury like this before?
No
Yes
If yes, explain:_____________________________________
______________________________________________________________________________________________________
On average, how severe is your pain? (circle)
0
1
2
3
4
5
6
7
8
9
10
Describe your pain? (circle)
Sharp
Stabbing
Dull
Aching
Throbbing
Burning
The pain is: (circle)
Constant
Intermittent
Does your pain wake you from your sleep? (circle)
No
Yes
How many nights a week? ____
Circle all that apply: Weakness
Stiffness
Loss of motion Swelling
Bruising
Catching
Tingling
Numbness
Since the problem started, it is: (circle)
Getting Better
Getting Worse
Unchanged
What makes your symptoms worse? Lifting
Overhead reaching
Lying on your shoulder
Throwing
Work
Bringing your arm down from a raised position
Other: _____________________________________________________
What makes your symptoms better?
Rest
Ice
Heat
Other____________________________________________
Circle medications you take currently or have tried in the past for this problem (add + sign to current medications)
Anti-inflammatory
Pain Medication
Steroid
Muscle Relaxant
Advil
Meloxicam
Sulindac
Tylenol
Hydrocodone
Prednisone
Flexeril
Motrin
Celebrex
Piroxicam
Tramadol
Oxycodone
Medrol Dose Pack
Skelaxin
Ibuprofen
Voltaren
Indocin
Ultracet
Soma
Aleve
Diclofenac
Indomethacin
Lortab
Cyclobenzaprin
Naproxen
Arthrotex
Lodine
Norco
Mobic
Clinoril
Etodolac
Percocet
Have you had the following treatments?
Injection
Date of injection:_____________________________________
Was it helpful? □Y □N
□Y □N
For how long did the injection give you relief? ____________________________________
Physical Therapy
Name of physical therapy facility: ______________________________________________
□Y □N
What date did you start and how long did you attend?______________________________
Was it helpful? □Y □N
HEP*
*HEP refers to a home exercise program given to you by a physical therapist or doctor.
□Y □N
Activity Modification* □Y □N
*Activity modification refers to avoiding activities that exacerbate your pain/symptoms.
Have you had an MRI for this problem? No
Yes Where was the MRI done at?_________________Date of MRI________
_
Have you already had surgery for a problem in this same area recently or in the past? □Y □N
Procedure:___________________________ Surgeon:___________________ City:_________________ Date:____________
Procedure:___________________________ Surgeon:___________________ City:_________________ Date:____________
What is your current work status? □Regular □Light Duty □Not working due to this problem □Disabled □Retired □Student
Shoulder Form
Name:___________________________________________________
Job description:____________________________________________
Students Only
Employer:_________________________________________________
School:______________________________
Primary Care Provider:_______________________________________
Grade:_______________________________
Who referred you:___________________________________________
Sport:________________________________
Position:_____________________________
Did you have an Injury?
Yes
No
Date of Injury:_______________________
When did your symptoms start:______________________
Place of Injury:______________________
Your symptoms started: (circle)
gradually
suddenly
Explain what happened: ________________________
Explain any details: ________________________________
_____________________________________________
__________________________________________________
_____________________________________________
__________________________________________________
_____________________________________________
__________________________________________________
_____________________________________________
__________________________________________________
_____________________________________________
__________________________________________________
Have you had a problem/Injury like this before?
No
Yes
If yes, explain:_____________________________________
______________________________________________________________________________________________________
On average, how severe is your pain? (circle)
0
1
2
3
4
5
6
7
8
9
10
Describe your pain? (circle)
Sharp
Stabbing
Dull
Aching
Throbbing
Burning
The pain is: (circle)
Constant
Intermittent
Does your pain wake you from your sleep? (circle)
No
Yes
How many nights a week? ____
Circle all that apply: Weakness
Stiffness
Loss of motion Swelling
Bruising
Catching
Tingling
Numbness
Since the problem started, it is: (circle)
Getting Better
Getting Worse
Unchanged
What makes your symptoms worse? Lifting
Overhead reaching
Lying on your shoulder
Throwing
Work
Bringing your arm down from a raised position
Other: _____________________________________________________
What makes your symptoms better?
Rest
Ice
Heat
Other____________________________________________
Circle medications you take currently or have tried in the past for this problem (add + sign to current medications)
Anti-inflammatory
Pain Medication
Steroid
Muscle Relaxant
Advil
Meloxicam
Sulindac
Tylenol
Hydrocodone
Prednisone
Flexeril
Motrin
Celebrex
Piroxicam
Tramadol
Oxycodone
Medrol Dose Pack
Skelaxin
Ibuprofen
Voltaren
Indocin
Ultracet
Soma
Aleve
Diclofenac
Indomethacin
Lortab
Cyclobenzaprin
Naproxen
Arthrotex
Lodine
Norco
Mobic
Clinoril
Etodolac
Percocet
Have you had the following treatments?
Injection
Date of injection:_____________________________________
Was it helpful? □Y □N
□Y □N
For how long did the injection give you relief? ____________________________________
Physical Therapy
Name of physical therapy facility: ______________________________________________
□Y □N
What date did you start and how long did you attend?______________________________
Was it helpful? □Y □N
HEP*
*HEP refers to a home exercise program given to you by a physical therapist or doctor.
□Y □N
Activity Modification* □Y □N
*Activity modification refers to avoiding activities that exacerbate your pain/symptoms.
Have you had an MRI for this problem? No
Yes Where was the MRI done at?_________________Date of MRI________
_
Have you already had surgery for a problem in this same area recently or in the past? □Y □N
Procedure:___________________________ Surgeon:___________________ City:_________________ Date:____________
Procedure:___________________________ Surgeon:___________________ City:_________________ Date:____________
What is your current work status? □Regular □Light Duty □Not working due to this problem □Disabled □Retired □Student