"*" indicates required fields Patient First Name*Patient Last Name*Today’s DateD.O.B.AgePCPReferred to Dr. Diaz byI amSelect an option...Right handedLeft handedAmbidextrousOccupation (If retired, please indicate so and list prior occupation)Please list your recreational interests (sports, instruments played, hobbies, etc)Reason for today’s visitDate of onsetWas there a specific injury? Yes No Are your current symptoms work-related? Yes No Somewhat Are you able to keep performing your job? Yes No Somewhat If not, are you able to perform modified duty? Yes No If not, when was the last time you worked?Are your current symptoms the result of an accident? Yes No Road traffic accident? Yes No Boating accident? Yes No Is there litigation pending related to this injury? Yes No Maybe If yes, please explain. Use back of this form if necessary.Please describe your symptoms by checking all that apply: Sharp or stabbing Dull or aching Radiating Throbbing Constant Intermittent Activity-related Pain at rest Numbness Weakness Stiffness Feeling of giving way Do your symptoms wake you up at night? Often Sometimes Never Please describe how you are limited by your symptoms.List anything that alleviates or lessens your symptoms (e.g. certain positions, splinting, medication, rest).List anything that aggravates your symptoms.If you are having shoulder symptoms, please check all that apply: Pain with overhead motion Pain with heavy lifting or repetitive activity Pain while sleeping on your affected side Loss of strength Associated neck pain Stiffness or loss of motion Pain with reaching around your back Pain while bringing your arm across your body Feelings of instability or giving way Popping, locking, catching, or grinding Pain, numbness, or tingling that radiate past elbow Other If you are having hand, wrist, or elbow symptoms, please check all that apply:Loss of feeling in fingers thumb index middle ring little Untitled Loss of dexterity or fine motor skills (e.g. buttoning shirt, putting on earrings, handwriting, handling small objects) Stiffness or loss of motion Deformity Swelling Locking, catching, or snapping Pain with heavy or repetitive activity Pain with grip Loss of grip strength Discoloration of fingers Cold intolerance
