occupation: social security number: which elbow is involved: …€¦ · arm pain then elbow pain...
TRANSCRIPT
Elbow History
Name: ________________________________________________Date of Birth: ____________
Occupation: ______________________Social Security Number: ________________________
Which elbow is involved: (C One) Right Left Both
When did symptoms first appear? Date:________________________
How did symptoms occur? (Check one)Injury (what happened) ______________________________________________SpontaneousArm pain then elbow painNeck pain then elbow painOther
If injured, how did injury occur? (Check all that apply)Sports related (which sport) ___________________________________________Fall or direct injury to elbowMotor vehicle accidentInjury to neck or arm, and then elbow painOther (describe) ____________________________________________________
What treatment have you had? (Check all that apply)
Who evaluated pain? Name: ________________________________________________
Name: ________________________________________________
X-rays Date:________________________
Results:___________________________________________________
MRI or CAT scan Date:________________________
Results:__________________________________________
Past medications, for elbow (please list) _____________________________________________
_____________________________________________________________________________
Please list any anti-inflammatory mediations you currently take: _________________________
_____________________________________________________________________________
Are you taking any anti-spasm medication? es (If yes, please list)
_____________________________________________________________________________
Have you had physical therapy for your elbow? If yes, where? ___________________
Dates: From:____________________ To:____________________
Have you had any injections in your elbow? Dates:____________________
Please list any surgeries (Date & Type; i.e. arthroscopy, reconstruction)
Date Type
1.___________________ ____________________________________________
2.___________________ ____________________________________________
3.___________________ ____________________________________________
Today’s Date: ______________
No Y
es No Y
Page 2 Elbow History
Current Symptoms: _____________________________________________________________
_____________________________________________________________________________
What is the level of your pain? (Check one in each column)
Mild Dull No ache
Moderate Sharp (Knife-like) Intermittent ache
Severe Burning Constant ache
Where is the pain located? (Check all that apply)
Front of elbow
Back of elbow
Side of elbow
Neck
Arm
What makes the elbow pain worse? (Check all that apply)
Any use of the arm Sports only Any sleeping position
Any activity when hand is above shoulder level
Other_____________________________________________________________
What improves pain? (Check all that apply)
Physical therapy Injections Ice Heat Rest Surgery
Medication: Type_________________ Exercises: Type________________________
Other___________________________________________________________________
What are your functional limitations?
Unable to work
Unable to do work above elbow level – job is restricted
Unable to comb hair
Unable to perform in sports
Type of sports ____________________________________________________
Unable to dress completely (i.e. shirt, coat, bra, etc.)
Unable to perform heavy lifting only
Other_____________________________________________________________
Other bone or joint problems:
Pain, Where? ______________________________________________________
Swelling, Where? ___________________________________________________
Surgery? __________________________________________________________
Name_________________________________D.O.B__________
Please mark on the scale your level of pain for the area being surveyed only.
Please only make ONE mark.Please DO NOT associate a number with the scale (such as from 1 – 10 scale).
Please DO NOT mark a range.
� EXAMPLES EXAMPLES EXAMPLES EXAMPLES EXAMPLES EXAMPLES�
CORRECT
I DO NOT MY PAINHAVEANY -------------------------------------------------------------- COULD NOT
PAIN BEWORSE
INCORRECT
I DO NOT 6-7 MY PAINHAVEANY -------------------------------------------------------------- COULD NOT
PAIN BEWORSE
INCORRECT
I DO NOT MY PAINHAVEANY -------------------------------------------------------------- COULD NOT
PAIN BEWORSE
� EXAMPLES EXAMPLES EXAMPLES EXAMPLES EXAMPLES EXAMPLES�
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PLEASE MARKYOUR PAIN LEVELBELOW.
I DO NOT MY PAINHAVEANY ----------------------------------------------------------------------- COULD NOT
PAIN BEWORSE Instructions: Using the space bar, move the cursor along the line, then type a lower case l in the location that corresponds to your pain level.
Name_________________________________D.O.B__________
ELBOW EVALUATION/COMPLICATION FORMPatient Information
SUBJECT LAST NAME FIRST NAME MI
SOCIAL SECURITY NUMBER SIDE DATE OF EXAM Weight lbs SURGEON NAME- - _______________
Left Right MM DD YYASES PATIENT SELF EVALUATION
PLEASE HAVE PATIENT COMPLETE THIS PAGEPAIN
YES NO1. Are you having pain in your elbow? .....................................................................2. Do you have pain in your elbow at night? ............................................................3. Do you take pain medication (aspirin, Advil, Tylenol, etc.)?.................................4. Do you take narcotic pain medication (codeine or stronger)? .............................5. How many pills do you take each day (average)?6 On a scale from 0-10, how bad is your pain today? (check one)
(0 = No pain at all; 10 = Pain as bad as it can be.)
0 1 2 3 4 5 6 7 8 9 10
INSTABILITY1. Does your elbow feel unstable (as if it is going to dislocate)? Yes No2. On a scale from 0-10, how unstable is your elbow (check one)
(0 = Very stable; 10 = Very unstable.)
0 1 2 3 4 5 6 7 8 9 10
ACTIVITY OF DAILY LIVING (ADL)Indicate your ability to do the following activities: Unable Very Somewhat Not
to do difficult difficult difficult1. Put on a coat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Sleep on your painful or affected side. . . . . . . . . . . . . . . . . . . . . . . .
3. Wash back/fasten bra in back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Manage toiletting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Comb hair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Reach a high shelf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Lift 10 lbs. above elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8. Throw a ball overhand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Do usual work (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10. Do usual sport (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name_________________________________D.O.B__________
SF-36 Health SurveyPatient Information
Subject Last Name First Name MI
Social Security Number Today’s Date Surgeon Name
M M D D Y Y
INSTRUCTIONS:This survey asks for your views about your health. All information that you furnish will be held in strict confidence. Please
answer every question by filling in the appropriate response. If you are unsure about how to answer a question, please give thebest answer you can. Please do not leave a question blank. Mark all answers with an “X.”
1.) In general, would you say your health is: (Mark one response)Excellent Very Good Good Fair Poor
2.) Compared to one year ago, how would you rate your health in general now? (Mark one response)Much better now than one year ago Somewhat worse now than one year agoSomewhat better now than one year ago Much worse now than one year agoAbout the same now as one year ago
3.) The following questions are about activities you might do during a typical day. Does your health now limit you inthese activities? If so, how much? (Mark one response on each line)
a. Vigorous activities, such as running, lifting heavyobjects, participating in strenuous sports
b. Moderate activities, such as moving a table,pushing a vacuum cleaner, bowling, or playing golf
c. Lifting or carrying groceries
d. Climbing several flights of stairs
e. Climbing one flight of stairs
f. Bending, kneeling, or stooping
g. Walking more than a mile
h. Walking several blocks
i. Walking one block
j. Bathing or dressing yourself
a. Cut down on the amount of time you spent on work or other activities
b. Accomplished less than you would like
c. Were limited in the kind of work or other activitiesd. Had difficulty performing the work or other activities
(for example, it took extra effort)
YES,LimitedA Lot
YES,LimitedA Little
YES NO
No, NotLimitedAt All
4.) During the past 4 weeks, have you had any of the following problems with your work or other regular daily activitiesas a result of your physical health? (Mark one response on each line)
SF–36 Health Survey Continued Page 1 of 2
Name_________________________________D.O.B__________
5.) During the past 4 weeks, have you had any of the following with your work or other regular daily activities as aresult of any emotional problems (such as feeling depressed or anxious)? (Mark one response on each line)
10.) During the past 4 weeks, how much of the time has your physical health or emotional problems interfered withyour social activities (like visiting with friends, relatives, etc.)? (Mark one response)
All of the time Most of the time Some of the time A little of the time None of the time
11.) How TRUE or FALSE is each of the statements for you? (Mark one response on each line)
6.) During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normalsocial activities with family, friends, neighbors, or groups? (Mark one response)
Not at all Slightly Moderately Quite a bit Extremely
7.) How much bodily pain have you had during the past 4 weeks? (Mark one response)None Very Mild Mild Moderate Severe Very Severe
8.) During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the homeand housework)? (Mark one response)
Not at all A little bit Moderately Quite a bit Extremely
9.) These questions are about how you feel and how things have been with you during the past 4 weeks. For eachquestion, please give the one answer that comes closet to the way you have been feeling. (Mark one response oneach line)
How much of the time during thepast 4 weeks –
a. Cut down the amount of time you spent on work or other activitiesa. Accomplished less than you would likea. Didn’t do work or other activities as carefully as usual
YES NO
All OfThe Time
Most OfThe Time
A Good BitOf The Time
Some OfThe Time
A Little OfThe Time
None OfThe Time
DefinitelyTRUE
MostlyTRUE
Don’tKnow
MostlyFALSE
DefinitelyFALSE
a. Did you feel full of pep?
b. Have you been a very nervous person?
d. Have you felt calm and peaceful
e. Did you have a lot of energy?
f. Have you felt downhearted and blue?
g. Did you feel worn out?
h. Have you been a happy person?
i. Did you feel tired?
c. Have you felt so down in the dumps that nothingcould cheer you up?
End of SF–36 Health Survey Page 2 of 2
a. I seem to get sick a little easier than other peopleb. I am as healthy as anybody I knowc. I expect my health to get worsed. My health is excellent
Name_________________________________D.O.B__________