Elbow Patient History Form Page 6

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I
E
Q
NITIAL
LBOW
UESTIONNAIRE
P
N
:
________________________
T
’
D
: __________________
ATIENT
AME
ODAY
S
ATE
S
E
ELF
VALUATION
1. Hand Dominance:
Right
Left
Use both equally
2. Are you having pain in your elbow?
Yes
No
3. Do you take pain medication (aspirin, Advil, Tylenol, etc.)?
Yes
No
4. Do you take narcotic pain medication (codeine or stronger)?
Yes
No
5. Does your elbow feel unstable (as if it is going to dislocate)?
Yes
No
6
How would you rate your upper extremity today as a percentage of normal?
______%
.
7. Do you have mechanical symptoms (
)?
catching, locking or grinding in your joint
Yes
No
Mayo Elbow Performance Score
1. Are you able to comb hair?
Yes
No
2. Are you able to feed yourself?
Yes
No
3. Are you able to perform personal hygiene tasks (ie, wiping)?
Yes
No
4. Are you able to put on a shirt?
Yes
No
5. Are you able to put on shoes?
Yes
No
R
M
ANGE OF
OTION
Please mark the estimated motion of your elbow
. (Mark one box for start and one box for finish)
How well can you STRAIGHTEN:
How well can you BEND:
0
45
120
45
120
145
VAS P
AIN
On the following scale of 0-10, please mark the average amount of pain you experience in your
elbow on a daily basis.
(PLEASE   C IRCLE   A   N UMBER)  
VAS F
UNCTION
On the following scale of 0-10, please mark what you consider to be the current overall function of
your elbow.
0
= my elbow is useless
10 = my elbow is normal
(PLEASE   C IRCLE   A   N UMBER)  
 
Useless    
 
 
 
 
 
Normal  
6

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