Patient Information

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
 
 
 

Affected Shoulder

 
 
 

Onset of symptoms

 
 
Which best describes how your symptoms began?
 
 
 
 
How long ago did the symptoms begin?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If you do not remember when your symptoms began, please describe how long you have been experiencing the symptoms:
 
Over the last:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Timing

 
 
 
 
 
 
 
 

Where did your problem start?

 
 
 
 
 
 
 

What caused your problem?

 
 
 
 
 
 
 
 
 

Pain

 
 
How much pain are you experiencing...
 
0 = no pain
 
10 = Intolerable
 
Now:
๐Ÿ™‚
 
 
 
 
 
 
 
 
 
 
๐Ÿ™
 
At its worst:
๐Ÿ™‚
 
 
 
 
 
 
 
 
 
 
๐Ÿ™

Quality

 
 
 
 
 
 
 
 

Associated signs and symptoms

 
 
 
 
 
 
 
 

Progression

 
 
 
 

What makes your pain worse?

 
 
 
 
 
 
 
 
 

What makes your pain better?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment History

 
 
Have you gone to any other locations for today's problem?
 
 
 
 
 
 
 
Have you had any of the following for today's problem?
 
 
 
 

Work History

 
 
Are you currently working?
 
 
 
 
 
Are you currently on any work restrictions?
 
 

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Online Health Forms by PatientLinkยฎ Enterprises Inc.
Oklahoma City, OK 73189
Form Number 512
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the โ€˜Submitโ€™ button when completed.