Today's Date MM DD YYYY Patient Name First Name Last Name Date of Birth MM DD YYYY Age Occupation/Job Referring Physician/PCP Location of Injury or Pain * Shoulder Elbow Wrist Hip Knee Ankle Other Other (Please List) Which Side(s) Dominant Arm * Right Left Problem(s) (please check all that apply) * Pain Weakness Instability - giving way - dislocation Stiffness Swelling If an injury, how did it occur? * No injury - just started hurting Sports Motor vehicle accident Work/job Injury Other If sports, which sport? If other, how? Is there a workers comp claim? Yes No Date the injury or symptoms began * MM DD YYYY Briefly describe how this problem began * Previous treatments other than surgery Previous surgery for this problem? How severe is the pain? 0 = none 10 = severe pain requiring hospitalization * Pain at resting level 0 1 2 3 4 5 6 7 8 9 10 At its worst * Option 1 Option 2 Do you have pain at night? * Yes No Does it wake you from sleep? * Yes No Are you currently working? * Yes No If you are working choose one Normal job Limited duty What makes your problem better? * What makes your problem worse? * Please describe your current limitations * Do you use walking aids? (cane, walker, etc) * List any allergies to medications * List all medications you are currently taking on a regular basis, including dose and frequency * Pain Scale Amount of pain 0 - no pain or discomfort 1, 2, 3 - Pain or discomfort is an annoyance 4, 5, 6 - Pain or discomfort INTERFERES with performing certain activities 7, 8, 9 - Pain or discomfort PREVENTS me from performing certain activities 10 - Pain or discomfort that 'sends me to the emergency room' Using the diagram below, please list the sections where you are experiencing pain with a number from the pain scale above. Thank you!
