Elbow Patient History Form Page 2
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8Elbow Patient History
Medical Record Number: _ _ _ _ _ _ _
Today’s Date:
___ / ___ / _____
___________________________
________________________
__________
____
First Name
Last Name
Middle Name
Suffix
___ / ___ / _____
_ _ _ - _ _ - _ _ _
______
___________
______________
Date of Birth
Social Security #
Gender
Race
Marital Status
Location of Problem:
Right Shoulder
Right Elbow
Neck
Left Shoulder
Left Elbow
If more than one, which is the worst?:
___________________
Date Problem Began (approximate): ____ / ____ / _______
Please describe your current problem:
New injury or problem (less than 6 weeks duration)
Subacute problem (6 weeks – 3 months duration)
Chronic Problem (problem has been treated for more than 3 months and never returned to normal)
Reinjury (you injured same area before, received treatment, had no problems until this new injury occurred)
-Date of Re-injury ____ / ____ / ______
Is your problem a result of an injury?
Yes
No
What caused your injury?
Fall
Fighting
Lifting
Twisting
Throwing
Collision/Contact
Reaching
Other: __________________
Check any of the following that happened at the time of your injury:
Felt pain
Heard pop
Had swelling
Discoloration
Dislocation
Fracture
Other: _________________________________
If your problem is the result of an injury, where did it occur? (Check one answer)
Home
Work
Motor Vehicle Accident
Exercise
Sporting Competition
Other: __________________________
Have you talked to a lawyer concerning your injury?
Yes
No
Are you receiving or have you applied for workers compensation concerning your injury?
Yes
No
Have you received previous treatment for your current problem?
(
Yes
No
If yes, please specify)
Medicine
Physical Therapy
Chiropractic
Alternative
Surgical (___ Number of surgeries)
Injections ( ___ Number of injections)
Are you having pain today?
Is your pain today:
Yes
No
Occasional
Constant
On a scale of 0 – 10, how would you score your pain today?
Check the words that best describe the character of the pain you are having today:
Aching
Nagging
Exhausting
Miserable
Unbearable
Tender
Stabbing
Shooting
Sharp
Gnawing
Penetrating
Tiring
Burning
Numb
Does the pain awaken you from sleep?
Never
Occasionally
Frequently
Does the pain keep you from falling asleep?
Never
Occasionally
Frequently
What time of day is your pain worst?
Morning
Afternoon
Evening
Night
All the time
What makes your pain better:
Rest
Ice
Sitting
Lying Down
Walking
Medication
Heat
Standing
Nothing in particular
Other: __________________
What makes your pain worse:
Rest
Ice
Sitting
Lying Down
Walking
Medication
Heat
Standing
Nothing in particular
Other: __________________
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