Elbow and Forearm Pain Form

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Transcription:

Elbow and Forearm Pain Form

Last Name First Name Date RIGHT LEFT My dominant hand? Right Left Does your elbow hurt? Yes No Yes No Does your forearm hurt? Yes No Yes No When did the problem start? Did you have an injury? Yes No Yes No If yes, what injury did you have? Where is the pain? Outer side Inner side Front Back Outer side Inner side Front Back What does the pain feel like? Dull Sharp Burning Dull Sharp Burning Is the pain? Constant Intermittent Constant Intermittent What makes it worse? Movement Keeping Still Movement Keeping Still How bad is the Pain None 0 12 3 4 5 6 7 8 9 10 Worst Possible Did you hurt yourself at work? Yes No None 0 12 3 4 5 6 7 8 9 10 Worst Possible Yes No Are you involved in litigation? Yes No Yes No CURRENT PROBLEM What is the problem with your elbow? When did it start? Did the problem start: Suddenly Gradually Is your problem getting: Worse Better Staying the same Was this the result of an injury? Yes No If yes, please describe how it happened:

PAIN QUESTIONS Do you have pain in your elbow? Yes No Is your pain: Constant Comes and goes Describe your pain: Dull Throbbing Aching Numbness Sharp Tight Burning Tingling Which best describes your pain? None Mild Moderate Severe Please rate your pain on the following scales: When it is at its worst At rest Lifting a heavy object When doing a task with repeated elbow movements At night Please circle the number that indicates your ability to do the following activities: Activity Right Arm Left Arm Button shirt to top 0 1 2 3 4 5 0 1 2 3 4 5 Manage toileting 0 1 2 3 4 5 0 1 2 3 4 5 Comb hair 0 1 2 3 4 5 0 1 2 3 4 5 Tie shoes 0 1 2 3 4 5 0 1 2 3 4 5 Eat with utensils 0 1 2 3 4 5 0 1 2 3 4 5 Carry a heavy object 0 1 2 3 4 5 0 1 2 3 4 5 Rise from chair pushing with arm 0 1 2 3 4 5 0 1 2 3 4 5 Do heavy household chores 0 1 2 3 4 5 0 1 2 3 4 5 Turn a key 0 1 2 3 4 5 0 1 2 3 4 5 Throw a ball 0 1 2 3 4 5 0 1 2 3 4 5 Do usual work-describe: 0 1 2 3 4 5 0 1 2 3 4 5 Do usual sport-describe: 0 1 2 3 4 5 0 1 2 3 4 5 0=Unable to do 5=No difficulty

Does your elbow allow you to sleep comfortably? Yes No Is your elbow comfortable with your arm at your side? Yes No What have you used for your symptoms? Did you get relief? Yes No Yes No Medication Type Physical Therapy How long did you attend? Injections Describe Surgery Describe Other Describe What tests have you already had concerning your elbow problem? x-rays arthrogram EMG CT scan MRI In general, would you say your health is: Excellent Very Good Good Fair Poor The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Yes, limited a lot Limited a little Not limited Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Climbing several flights of stairs

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? Yes No Accomplished less than you would like Were limited in the kind of work or other activities During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of emotional problems (such as feeling anxious or depressed)? Yes No Accomplished less than you would like Didn't do work or other activities as carefully as usual During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? Not at all A little bit Moderately Quite a bit Extremely These questions are about how you feel and how things have been with you during the last 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the last 4 weeks: All of- Most of- A good bit- Some of- A little of- None of the time Have you felt calm and peaceful? Did you have a lot of energy? Have you felt downhearted and blue?

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)? All of the time Most of the time Some of the time A little of the time N one of the time

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