Frank J. Schlehr, M.D., P.C.
Brandt D. Dubey, RPA-C, AT Craig M. Roberto, D.O. Erin C. Wiza, RPA-C
Fellow of American College of Orthopaedic Surgeons
Sports Medicine
Patient Intake Form - Shoulder
Patient Name ______Date ______
Occupation ______Age ______
Who is your Internist or Primary Care Physician?
Full Name ______Phone ______
Address ______
City, State, Zip ______
Who sent you to see us? Name ______ Same as above
Address ______Phone ______
History:
1)Chief Complaint:
a)Problem in the: Right Shoulder Left Shoulder Both (Which is worse? Right Left)
b)Hand Dominance? Right Left Ambidextrous
c)What is your chief complaint? ______
______
d)How long have you had this problem? ______
e)Is your problem getting: Worse Better Staying the same
f)Was this a result of an injury? Yes No
If yes, please describe how it happened: ______
______
2)Work-Related Injury:
a)Is this a work related injury? Yes No
b)Job title: ______
c)How long have you worked for this employer? ______
d)Date of injury: ______
e)Are you: off workmodified duty full duty
f)If you are not working full duty, what date did you last do so: ______
g)Is this injury related to any litigation? Yes No
h)Was this the result of a motor vehicle accident? Yes No Date: ______
3)Timing
a)Is your pain worse at any particular time of the day? Morning Evening Night
b)Does your shoulder allow you to sleep comfortably? Yes No
c)Frequency of the pain? Occasional (How often?) ______Constant
4)What makes your symptoms better? (Please check all that apply)
Nothing Rest Activity PT Moving the Shoulder Medicine______ Injections
5)Activity-Related Symptoms:
a)Is your shoulder comfortable at rest?Yes No
b)Does your shoulder allow you to perform your normal activities of daily living
(other than work or sport)? Yes No
c)Does your shoulder allow you to participate in sports? Yes No
d)Can you participate in sports at the level of competition you desire? Yes No
6)What makes the pain worse? (Please check all that apply) Resting Any shoulder motion Lifting arm itself Lifting any weight Throwing PT Sleeping on the shoulder
Driving Overhead movements Weightlifting(what exercises?) ______
7)Does your shoulder give out? Never At the time of original injury Regularly
Partially If yes, ____# of times, First time(year) _____ Last Time(year) ______
Describe position of arm when it gives out ______
8)Shoulder Appearance: Normal Swollen Muscle Shrinkage Lump I can feel
9)Shoulder Mobility: Normal Limited ability to elevate Unable to place behind back
10)Please list all medications you are currently on with dosage and frequency:
______
______
______
______
Prior treatment:
11)Have you seen another physician for this problem? YesNo
What was their diagnosis? ______
What was the treatment? ______
12)Please list all related past surgeries and hospitalizations:
Surgery/hospitalization Date Physician
______
13)Have you had previous X-rays? Yes No
Month/Day/Year Location Results
___/___/______
___/___/______
14)Have you had a CT Scan, MRI or Bone Scan? Yes No
Month/Day/Year Location Results
___/___/______
___/___/______
15)Have you ever had Physical Therapy? Yes No How long? ______
Where? ______Was it helpful? Yes No
Shoulder Symptoms:
16)If PAIN is one of your complaints, please complete the following questions.
Is your pain located in the: FrontBack TopDeep Inside AC Joint Shoulder Blade
Rate the average intensity of your pain/discomfort. (0=no pain, 10=severe pain)
0 1 2 3 4 5 6 7 8 9 10
Describe your Pain:Intermittent Constant DullSharp Throbbing
TightBurning Tingling
17)Do you ever have any of these symptoms?
YESNO If yes, describe
Stiffness ______
Numbness ______
Swelling ______
Instability ______
Weakness ______
Painful ______
Grinding ______
Locking ______
Other ______
Numbness Where? ShoulderArm Forearm Hand
18)Have you ever had/currently have any neck problems? Yes No
Please describe ______
If yes, have they ever been evaluated? Yes No
Tests: ______Results: ______
19)Have you ever had an injection in the shoulder? Yes No
When? ______
Type? Cortisone
Visco-supplementation: Synvisc Euflexxa Orthovisc Supartz
Did it provide you any relief? Yes No For how long? ______
20)Activities you unable to do: (check all that apply) None Feed myself Do hair
Housework Recreational activities Competitive sports Overhead work
21)How do you sleep?
Normally On back On stomach Inside arm at side Arm up, shoulder
Patient Signature______Date ______
Reviewed by: ______Date: ______
Please Print Clearly: Patient Full Name______1 | Page