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 MRI 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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