UW Medicine. Affix Pt Label Here. Name: U Number: DOB: New Shoulder & Elbow Patient Form

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New Shoulder & Elbow Patient Form UW Medicine Name Date Age How did you hear about us? Requesting Physician Name UPIN # Address City State Zip Code Phone Fax email Primary Care Physician Name UPIN # Address City State Zip Code Phone Fax email Chief Complaint - Please describe the problem that brings you into the office today: Social History Tobacco Use Mark Only One: Never Packs per day: 0.5 Years: 5 Date quit: Types: Cigarettes Quit 1 10 Pipe Passive 1.5 15 Cigars Yes 2 20 Snuff Chew Alcohol Use Drug use No Yes Drinks per week: # Can(s) of beer # Drink(s) containing 0.5 oz of alcohol # Glass(es) of wine # Shot(s) of liquor No Yes Use per week: 1 2 5 10 IV drug use: No Yes Are you currently working? Yes No What is or was your occupation? 1

Family History Please check if any of your family members have had the following: ADHD Alcohol/Drug Allergic/Atopic Disease Arthritis Autoimmune Cancer Colorectal cancer Diabetes Gastrointestinal (GI) Genitourinary (GU) Heart Hypertension Lipids Osteoporosis Psych Pulmonary Stroke Thyroid Other Past Medical History 1. Do you have, or are you being treated for, any of the following (please check all that apply): Allergic rhinitis (477.9) Anxiety (308.0) Asthma (493.90) Bipolar (296.8) Bleeding/clotting disorder (286.9) Cancer (CA) (234.9) Chemical dependency Drug (304.90) Alcohol (303.9) Chronic lung disease/emphysema (COPD) (496) Congestive heart failure (CHF) (428.0) Coronary artery disease (CAD) (414.00) Depression (311) Diabetes Using insulin (IDDM) (250.01) Not using insulin (NIDDM) (250.00) Fibromyalgia (729.1) Heart attack (MI) (410.9) Hepatitis (please specify type(s)) (573.3) High blood pressure (HTN) (401.9) High cholesterol (272.4) Psoriasis (696.5) Rheumatoid Arthritis (RA) (714.0) Stroke (434.91) Transient ischemic attack (TIA) (435.9) Thyroid disorder Hypothyroidism (244.9) Hyperthryroidism (242.90) Sleep Apnea (780.57) Other Sleep disorder/trouble sleeping/(insomnia) (780.50) Ulcers Stomach ulcers (531) Peptic ulcer disease (PUD) (533) Other (specify) Heartburn (787.1) Reflux (GERD) (530.81) NO PAST MEDICAL HISTORY (1000) 2

Past Surgical History 1. What studies have you had for this problem? (Check all that apply) X-rays CT MRI Arthrogram Nerve Study (EMG) Bone Scan Other: 2. Have you had any previous surgeries for this problem? Yes No Surgeries for This Problem and if they helped Surgeon Year 3. List all Other Bone/Joint (Orthopedic) Surgeries. Surgeries Year 4. Please list/check all Other Surgeries you have had. Surgeries Year No previous surgeries (100) Appendix (appendectomy) (44950) Gall bladder (cholecystectomy) (47600) Bypass/open heart (CABG) (33999) Hernia Repair (49585) Hysterectomy (581550) Tonsils removed (tonsillectomy) (42820) Other Surgeries Year Musculoskeletal 20999 Neck/Chest 21899 Arthroscopy 29909 Spine 22899 Shoulder 23929 Pelvis/Hip 27299 Upper Arm/Elbow 24999 Femur/Knee 27599 Forearm/Wrist 25999 Leg/Ankle 27899 Hand/Finger 26989 Foot/Toes 28899 3

Allergies UW Medicine 1. Do you have any allergies? Yes No if so, please list To Medications? To Foods? 2. Are you allergic to latex? Yes No 3. Are you allergic to iodine? Yes No Medications 1. Are you taking any pain medications YES NO If so, please list all: Pain Medications Dose Times per day Reason for taking 2. All other Medications Dose Times per day Reason for taking 4

Please Check one: Right Handed Left Handed Ambidextrous Is this a work related problem? Yes No If yes, list your OWCP Claim# or L&I Claim# If disabled, when did you last work? Is a lawyer involved with this problem? If so, name/address History of Present Illness 1. Location - where is the problem located? Right Side Left Side Both Sides Shoulder Elbow Other 2. Severity - Please rate the intensity of your joint Pain/discomfort: (1 = No Pain, 10 = Severe Pain) 1 2 3 4 5 6 7 8 9 10 3. Context - How did this problem begin? 4. Modifying Factors - What makes your symptom(s) worse? Using affected side Work Exercise Don t know What improves your symptom(s)? Rest Ice Heat Exercise NSAIDs (anti-inflammatories) 5

Review of Systems Do you have or had any of the following Problems? (Check any that apply) General Eye weight gain weight gain loss fatigue glasses/contacts cataracts UW Medicine insomnia fever night-sweats/chills glaucoma Comments Ear/Nose/Throat Heart Lung Stomach Muscles/ Bones Urinary Tract Skin Neurology Mental Health Endocrine sinus trouble hearing loss irregular heartbeat high blood pressure chest pain shortness of breath difficulty breathing decreased appetite constipation heartburn arthritis fractures kidney stone bladder/kidney infections masses blisters seizures tingling anxiety depression increased thirst diabetes ringing in ears fluttering in chest coronary disease lung disease persistent cough nausea diarrhea hepatitis A B C sprains prostate problems painful urinating non-healing wounds dermatitis numbness severe headaches other (please describe) thyroid Blood/Lymph Immunological bleeding or clotting problems anemia swollen or enlarged lymph nodes hay fever HIV/AIDS lupus SANE Score How would you rate your affected and opposite extremity today as a percentage of normal (0% to 100% scale with 100% being normal)? Right Side: % Left Side: % Physician Signature Date 6

If you have a shoulder problem, please fill out this Simple Shoulder Test for BOTH of your shoulders. Simple Shoulder Test Please answer YES or NO for BOTH of your shoulders RIGHT LEFT YES NO YES NO 1 Is your shoulder comfortable with your arm at rest by your side? 1 2 Does your shoulder allow you to sleep comfortably? 2 3 Can you reach the small of your back to tuck in your shirt with your hand? 3 4 Can you place your hand behind your head with the elbow straight out to the side? 4 5 6 7 Can you place a coin on a shelf at the level of your shoulder without bending your elbow? Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow? Can you lift eight pounds (a full gallon container) to the level of your shoulder without bending your elbow? 5 6 7 8 Can you carry twenty pounds at your side with this extremity? 8 9 Do you think you can toss a softball under-hand twenty yards with this extremity? 9 10 Do you think you can toss a softball over-hand twenty yards with this extremity? 10 11 Can you wash the back of your opposite shoulder with this extremity? 11 12 Would your shoulder allow you to work full-time at your regular job? 12 7

If you have an elbow problem, please fill out this Elbow Shoulder Test for BOTH of your elbows. Simple Elbow Test Please answer YES or NO for BOTH of your elbows RIGHT LEFT YES NO YES NO 1 Is your elbow comfortable with your arm at rest by your side? 1 2 Does your elbow allow you to sleep comfortably? 2 3 Does your elbow allow you to reach the small of your back to tuck your shirt in? 3 4 Can you place your hand behind your head with the elbow straight out to the side? 4 5 Will your elbow allow you to pull on socks or stockings? 5 6 Does your elbow allow you to lift one pound to the level of your shoulder? 6 7 Can you use your arm to help you rise from a chair? 7 8 Will your elbow allow you to carry 20 pounds at your side? 8 9 Will your elbow allow you to comb your hair? 9 10 Will your elbow allow you to throw a ball with this arm? 10 11 Will your elbow allow you to wash the back of your opposite shoulder? 11 12 Would your elbow allow you to work full-time at your regular job? 12 8

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