UPPER EXTREMITY PATIENT EVALUATION
REFERRED BY:______NAME:______Age:__
□Right □ Left □ Both
□ Hand □ Wrist □ Elbow
Hand Dominance: □Right □Left □Ambidextrous
DATE of onset: ______(If you can’t remember exactly, please guess to the nearest date, month, or year.)
Type of Onset: □gradual □sudden □no injury □injury
How did it happen? Did it swell immediately? ______
______
Did you go to an emergency department? □ no □ yes Name: ______
Have you had a similar problem in the past? If so, describe:
______
CURRENT STATUS:
Does the pain extend/radiate anywhere else?: □no □yes, Where?______
Severity: □mild □moderate □severe □incapacitating
Frequency: □intermittent □occasional □constant □rare
Quality: □aching □burning □dull □piercing □sharp □throbbing
What makes the symptoms/ pain worse?: □lifting □pushing □pulling □reaching □grasping □gripping
□writing □typing □fine finger movement □exercising □work activities □daily activities
What helps you feel better?: □nothing □brace/splint □elevation □exercise □heat □ice □massage □injection □pain medication □mobility □physical therapy □rest □stretching
□ Other ______
Associated Symptoms: □bruising □crepitus(crackling) □popping □decreased mobility □ instability □numbness □tingling in the arms □spasms □swelling □tenderness □weakness □catching □stiffness
□difficulty going to sleep □night pain □night-time awakening
What activities does your pain prevent you from doing? ______
______
What has been done so far?
□ Surgery (type, doctor, and date): ______
□ X-rays and Date: ______
□ MRI and Date: ______
□ EMG and Date: ______
□ Other diagnostic testing and Date: ______
□ Injections: ______Relief felt:: □None □Minimal □Moderate □Significant
□ Physical Therapy: ______Relief felt: □None □Minimal □Moderate □Significant
□ Brace (Describe): ______Relief felt: □None □Minimal □Moderate □Significant
□ Medication taken for this problem: ______
During the last month, how frequently did you take medications for pain?
□Never □Daily □Several times a week □About once a week □Less than once a week
How much did medication help? □Complete relief □Moderate relief □Very little relief □No relief