Shoulder
After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
My provider is not in the list
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
Patient Information
*
Please provide the patient's name as it appears on their driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Shoulder Pain
* Required Information
*
Affected Shoulder
Left
Right
Onset of Symptoms
*
Which best describes how your symptoms began?
Due to an injury
Gradual onset (not due to an injury)
Sudden onset (not due to an injury)
How long ago did the symptoms begin?
1
2
3
4
5
6
7
8
9
10
More than 10
Days ago
Weeks ago
Months ago
Years ago
If you do not remember when your symptoms began, please describe how long you have been experiencing the symptoms:
Over the last:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16 or more
Weeks
Months
Years
*
Timing
Occasional
Intermittent
Daytime
Rare
Constant
Nighttime
Pain causes me to wake up from sleep
*
Where did your problem start?
Not sure
At work
Non-vehicle accident
During athletic activities
At home
Motor vehicle accident
*
What caused your problem?
Sleep position
Repetitive motion
Pulling
Reaching or throwing
Fall or direct blow
Lifting
Twisting
Not sure
Pain
How much pain are you experiencing...
0 = no pain
10 = Intolerable
*
Now:
🙂
0
1
2
3
4
5
6
7
8
9
10
🙁
*
At its worst:
🙂
0
1
2
3
4
5
6
7
8
9
10
🙁
Quality
Burning
Stinging
Aching
Sharp
Stabbing
Throbbing
Dull
Associated Signs and Symptoms
Locking or popping
Stiffness
Catching
Weakness
Numbness
Giving way or instability
Tingling in hand or fingers
*
Progression
Improving
Unchanged
Worsening
What makes your pain worse?
Turning my neck
Pulling
Lying down
Reaching
Pushing
Sneezing
Throwing
Activities overhead
*
What makes your pain better?
Medications
Physical therapy
Ice
Exercise
Injections
Heat
Using a sling
Chiropractor
Rest
Elevation
Previous surgery
Stretching
Anti-inflammatories
(aspirin type medicines)
Nothing makes the pain better
Treatment History
*
Have you gone to any other locations for today's problem?
Chiropractor
Orthopedic physician
Urgent care / Emergency room
Primary care provider
Physical therapy
None
*
Have you had any of the following for today's problem?
No
X-Ray
CT Scan
MRI
Work History
*
Are you currently working?
Yes
No
Disabled
Retired
*
Are you currently on any work restrictions?
No
Yes
Back
Next
Form processing, please wait...
IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
Online Health Forms by PatientLink® 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 ‘Submit’ button when completed.