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Microsoft word - questionnairefornewpatients_shoulder_.doc

Questionnaire for New Patients – Shoulder Injury
713 441 3560 – Phone 713 790 2054 – Fax (1) Please return this completed form to our office BEFORE your appointment either by fax or
mail. (2) Please bring any prior MRI films, x-rays, or medical records to the office with you
for your appointment. (3) Please bring a sleeveless shirt or tank top. Thank you. Your Name: _________________________________
Who is your primary care physician? _______________________________
When did you last see him / her? __________________________________
Past Medical History: Please check the appropriate boxes:
Have you ever had any of the following (in the past)?
‰ Shortness of Breath ‰ Slowly healing wounds ‰ Stomach ulcer ___ NORMAL, I’ve had none of the above
Review of Systems:
Do you currently have any of the following?
‰ Reaction of NSAID/anti-inflammatory medications (Advil, ibuprofen, Naproxen, ‰ Recent weight gain, recent weight loss ‰ Changes in vision, sensitivity to light, blurred vision, double vision ‰ Change in hearing, bloody noses, sore throat, cough ‰ Shortness of breath, chest pain, wheezing, coughing of blood ‰ Palpitations, light headedness, dizziness ‰ Loss of appetite, weight loss, pain with swallowing, nausea, vomiting, abdominal pain or bloating, blood in your stools, diarrhea, constipation ‰ Difficulty urinating, pain with urination, blood in your urine ‰ Rashes, insect bites, new skin lesions ___ NORMAL, I’ve had none of the above What Medications do you take? 1._____________________ 2._____________________ 3._____________________ 4._____________________ Are you allergic to any medications? ‰ Yes: ____________________ ‰ No Do you smoke? Yes (packs per day ______) ‰ No How much alcohol do you drink? ______________ What surgeries have you had in the past? 1.______________________ 2.______________________ 3.______________________ 4.______________________
Shoulder History:
‰ Right
‰ Left
When did your shoulder problem begin? ________________
How did it start?
‰ Sports Injury
‰ Work Injury
‰ Overuse (running, cycling, swimming)
‰ Work Overuse
‰ Gradually
‰ Spontaneously (for no apparent reason)
What treatment have you had for this shoulder injury?
‰ Medications
‰ Physical therapy
‰ Cortisone Injection
‰ Surgery
Have you had any of the following for this shoulder injury (Please bring the films to the
office with you!):
‰ X-ray
‰ CT scan
Have you had this problem before? ‰ Yes ‰ No What part of your shoulder hurts? ‰ Front ‰ Outer side (deltoid region) ‰ Back ‰ Upper ‰ Shoulder Blade ‰ Base of neck / trapezius region What makes the pain worse? ‰ Prolonged use ‰ Reaching or using over head ‰ Throwing or hitting a tennis serve ‰ Lifting weights (which exercises?________________) ‰ Pulling on object off a shelf (example: gallon of milk out of refrigerator) ‰ Pulling an object up from the floor (suitcase, etc) ‰ Tucking in a shirt Does the pain wake you up from sleep? ‰ Yes ‰ No If the pain is worse when you throw /serve, which part of the throw hurts the most? ‰ Cocking ‰ Ball release (or striking the tennis ball) ‰ Finishing the throw / follow through Do you have any of the following? ‰ Painful popping ‰ Sensation of catching (something getting caught / pinched between the bones) ‰ Coming out of joint ‰ Dead arm ‰ Pain radiating down arm (if so, where does it go ___________) ‰ Numbness in arm ‰ Swelling or discoloration of arm after throwing ‰ None of the above Has the shoulder ever come out of joint: ‰ Part way (Subluxation, the bones feel like they slip out of place) ‰ All the way (Dislocation) ‰ None of the above Describe your job’s physical demands: ‰ Manual Labor: including lifting, carrying, pulling, pushing, working with arms over head (eg, mechanic, construction, laborer, etc) ‰ Moderate: regular use of arms but not heavy. ‰ Office environment ‰ Student ‰ Other Are you working at your usual job ‰ Yes ‰ No, light duty ‰ No, off work due to injury ‰ No, off work for other reasons What were your typical most strenuous recreational activities before your shoulder problem began: ‰ High intensity sports (football, baseball, basketball, tennis, racquetball, etc) ‰ Moderate intensity sports ( recreational skiing, running, cycling, etc) ‰ Low intensity sports ( walking, golf, etc) ‰ Activities of Daily living What are your most strenuous recreational activities since your shoulder problem began: ‰ High intensity sports (football, baseball, basketball, tennis, racquetball, etc) ‰ Moderate intensity sports ( recreational skiing, running, cycling, etc) ‰ Low intensity sports ( walking, golf, etc) ‰ Activities of daily living What type of activities do you intend to return to after your shoulder problem resolves? ‰ High intensity sports (football, baseball, basketball, tennis, racquetball, etc) ‰ Moderate intensity sports ( recreational skiing, running, cycling, etc) ‰ Low intensity sports ( walking, golf, etc) ‰ Manual Labor ‰ Desk Job ‰ Activities of daily livingDo you lift weights for exercise/recreation? If so, how many times per week? ‰ Less than two times per week ‰ Two – three times per week ‰ More than three times per week ‰ Bodybuilder ‰ Don’t lift weights Have you had an MRI of this shoulder since this problem began? If so, what did the MRI show __________________________________ What prior injuries have you had to this shoulder? ‰ None ‰ Cartilage / Labral tear ‰ Dislocation ‰ Subluxation ‰ Sprain / strain ‰ Rotator Cuff Tear What Surgeries have you had on this shoulder? ‰ None ‰ Arthroscopy (year: _______) ‰ Labral repair (year: _______) ‰ Tightening of shoulder (year: _______) ‰ Bankart repair / reconstruction (year: ______) ‰ Debridement / cleaning out (year: _______) ‰ Rotator Cuff Repair (year: _______) ‰ Removal of outer portion of clavicle (year:_____) What are your goals for today’s visit: ‰ Gain information about condition ‰ Make sure you are not damaging shoulder ‰ Fix the problem as long as it does not involve surgery ‰ Fix the problem even if it requires surgeryPatient Signature ________________________________ Parent/Guardian Signature (if patient is a minor)_____________________ Thank you, David M. Lintner MD 6560 Fannin, Scurlock Tower Suite 400 Houston, TX 77030 713 441 3560 – Phone 713 790 2054 – Fax Revised November 2006


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