ORTHOPAEDIC - SHOULDER QUESTIONNAIRE

Today’s Date Height (feet/inches) Weight (pounds)

First Name Last Name

Date of Birth Age Occupation Gender: Male Female

Referring Physician

Which shoulder is causing the problem? Right Left Both

Hand dominance? Right Left Ambidexterous

HISTORY

When did your symptoms begin?

Did you have an injury? Yes No If yes, when did the injury occur?

How did the injury occur?

Was the injury work related? Yes No Not Sure

What treatment have you tried?

Medication (please list below) Physical Therapy Cortisone Injection Activity Modification Surgery (please list below)

If you checked “Medication”, please list pain medications you are taking. Please include dosages and frequency.

Name of Medication Dose Frequency

If you checked “Surgery”, please list the type of surgery, name of the surgeon, and date you had surgery:

Surgery Physician Date

Please list tests done to evaluate your problem:

Test Date Where? Results

X-Ray

MRI

Bone Scan

CT Scan

EMG/NCV

Other

Do you experience any of the following? (Check all that apply)

Pain Weakness Radiating Pain Numbness and Tingling Loss of Motion Grinding If yes, how far down the arm? Where? Catching/Popping When is it present? When is it present?

Where is your shoulder pain located? Front Back Side Top Neck

What best describes the pain? Sharp Dull Burning Aching Constant Activity Related

Does your shoulder pain keep you awake at night? Yes No

What activities aggravate your symptoms? Reaching behind your back Lifting Throwing Reaching across your body Pulling Other (please describe) Reaching over your head Pushing 5/2013 | Page 1 of 2 | 10014

How does your shoulder limit your activities?

What makes your symptoms better?

Does your shoulder slip out of joint or feel unstable? Yes No

If yes, what activities cause this?

Have you ever had a dislocation? Yes No

If yes, how many and at what age?

Please indicate your pain/discomfort on the scale below:

No pain Slight Mild Moderate Severe Excruciating Pain as bad as it could be

OFFICE USE ONLY. TO BE COMPLETED BY YOUR PROVIDER. Height Weight

ROM: Right / Left Crepitus: 1+2+3 Strength: Right / Left

FF / GH Supra /

ABD / SUBACR ER /

ER / IR /

IR /

ER-AD /

SPECIAL TESTS:

NEER CA

HAWK AC

CRANK ANT APP

O’BRIEN POST APP

SPEED SULCUS

GEN LAX

NECK:

TENDER

LROM

SPURLING’S

Patient Signature: Date:

Provider Signature: Date:

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5/2013 | Page 2 of 2 | 10014