Elbow Patient History Form Page 7
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8F
UNCTION (A
S
E
S
S
)
MERICAN
HOULDER AND
LBOW
OCIETY
CORE
Please note your ability to do the following daily activities, or if you were to try such activities (Best Guess):
0 = Unable
t o do, 1 = Very
d ifficult
t o do, 2 = Somewhat
d ifficult, 3 = Normal
( Check ONLY ONE answer)
Right Arm
Left Arm
1. Put on a coat
0
1
2
3
0
1
2
3
2. Sleep on your affected side
0
1
2
3
0
1
2
3
3. Wash back/connect bra in back
0
1
2
3
0
1
2
3
4. Manage toileting
0
1
2
3
0
1
2
3
5. Comb hair
0
1
2
3
0
1
2
3
6. Reach a high shelf
0
1
2
3
0
1
2
3
7. Lift 10lbs above shoulder
0
1
2
3
0
1
2
3
8. Throw a ball overhead
0
1
2
3
0
1
2
3
9. Do usual work
0
1
2
3
0
1
2
3
(Please describe usual work): ___________________________________________
10. Do usual sport
0
1
2
3
0
1
2
3
(Please describe usual sport): ___________________________________________
IF YOU HAVE HAD SURGERY, please answer the following questions. Otherwise, please
leave them blank.
a. Does your operated arm feel numb in any region?
Yes
No
b. Does your operated arm feel weaker to any activity now than before?
Yes
No
c. Does your operated arm feel more painful now than before surgery?
Yes
No
d. Would you have the same procedure performed upon yourself again?
Yes
No
e. How would you rate your personal satisfaction with your surgery? (circle one)
Excellent
Good
Satisfactory
Unsatisfactory
7
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0 votes
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