|
Please select only the part of the body that you are scheduled to be evaluated for today
|
Placeholder
|
|
Shoulder
|
Knee
|
|
Hip
|
Foot & Ankle
|
|
Elbow
|
|
|
Shoulder History
|
Placeholder
|
|
Dominant Arm?
|
Which shoulder is symptomatic?
|
|
What type of shoulder symptoms are you having?
• • •
|
What caused your pain?
|
|
Have your symptoms been:
|
Does your shoulder hurt:
|
|
Are you taking any medications for your symptoms?
|
Is so, what medication (with dosage and frequency)?
|
|
Have you injured the symptomatic shoulder in the past?
|
If so, when did it occur and what was the diagnosis?
|
|
Please indicate all formal treatment(s) you have received thus far:
|
|
|
MRI?
|
Date and name of facility?
|
|
Physical Therapy?
|
Did this treatment help?
|
|
How many sessions?
|
|
|
Cortisone Injection(s)
|
Did this treatment help?
|
|
How many and date of last injection?
|
|
|
Other Treatments
|
Comment
|
|
Did this treatment help?
|
|
|
ASES Assessment
|
Placeholder
|
|
How bad is your pain today?
|
|
|
Select your ability to do the following:
|
|
|
Put on a coat (Left arm)
|
Put on a coat (Right arm)
|
|
Sleep on your painful / affected side (Left arm)
|
Sleep on your painful / affected side (Right arm)
|
|
Wash back/do up bra in back (Left arm)
|
Wash back/do up bra in back (Right arm)
|
|
Manage toileting (Left arm)
|
Manage toileting (Right arm)
|
|
Comb hair (Left arm)
|
Comb hair (Right arm)
|
|
Reach a high shelf (Left arm)
|
Reach a high shelf (Right arm)
|
|
Lift 10 lbs. above shoulder (Left arm)
|
Lift 10 lbs. above shoulder (Right arm)
|
|
Throw a ball overhand (Left arm)
|
Throw a ball overhand (Right arm)
|
|
Do usual work (Left arm)
|
Do usual work (Right arm)
|
|
Please list what your usual work involves
|
|
|
Do usual sport (Left arm)
|
Do usual sport (Right arm)
|
|
Please list what your usual sport involves
|
|
|
Knee History
|
Placeholder
|
|
Which knee is symptomatic?
|
If both, which one hurts more?
|
|
What types of symptoms are you having?
• • •
|
What caused your symptoms?
|
|
When did your symptoms begin?
|
Have your symptoms been:
|
|
Does your knee hurt during:
• • •
|
|
|
Are you taking any medications for your symptoms?
|
Is so, what medication (with dosage and frequency)?
|
|
Have you injured the symptomatic knee in the past?
|
If so, when did it occur and what was the diagnosis?
|
|
Please indicate all formal treatment(s) you have received thus far:
|
|
|
Knee MRI?
|
Date and name of facility?
|
|
Physical Therapy (Knee)?
|
Did this treatment help?
|
|
How many session?
|
|
|
Knee Injection(s)
|
Did this treatment help?
|
|
How many and date of last injection?
|
|
|
Other Treatments (Knee)
|
Comment
|
|
Did this treatment help?
|
|
|
Lysholm Knee Scoring Scale
|
Placeholder
|
|
Section 1 – Limp
|
Section 2 – Using cane or crutches
|
|
Section 3 – Locking sensation in the knee
|
Section 4 – Giving way sensation from the knee
|
|
Section 5 – Pain
|
Section 6 – Swelling
|
|
Section 7 – Climbing stairs
|
Section 8 – Squatting
|
|
2000 IKDC Subjective Knee Evaluation
|
|
|
Symptoms
|
New Short Text Field
|
|
Grade symptoms at the highest activity level at which you think you could function
|
|
|
without significant symptoms, even if you are not actually performing activities at this level.
|
|
|
What is the highest level of activity that you can perform without significant knee pain?
|
|
|
During the past 4 weeks, or since your injury, how often have you had pain?
|
|
|
If you have pain, how severe is it?
|
|
|
What is the highest level of activity that you can perform without significant swelling in your knee?
|
|
|
During the past 4 weeks, or since your injury, did your knees lock or catch?
|
|
|
What is the highest level of activity that you can perform without significant giving way in your knee?
|
|
|
Sports Activities
|
New Short Text Field
|
|
What is the highest level of activity that you can participate in on a regular basis?
|
|
|
How does your knee affect your ability to:
|
|
|
Going up stairs
|
Going down stairs
|
|
Kneel on the front of your knee
|
Squat
|
|
Sit with your knee bent
|
Rise from a chair
|
|
Run straight ahead
|
Jump and land on your involved leg
|
|
Stop and start quickly
|
|
|
Function
|
New Short Text Field
|
|
Function prior to knee injury (no points for this category)
|
|
|
Current function of your knee (points recorded for this category)
|
|
|
Hip History
|
New Short Text Field
|
|
Which hip is symptomatic?
|
If both, which one hurts more?
|
|
What types of symptoms are you having?
• • •
|
What caused your symptoms?
|
|
When did your symptoms begin?
|
Have your symptoms been:
|
|
Have you noticed if one leg is shorter than the other?
|
|
|
Are you taking any medications for your symptoms?
|
Is so, what medication (with dosage and frequency)?
|
|
Have you injured the symptomatic hip in the past?
|
If so, when did it occur and what was the diagnosis?
|
|
Please indicate all formal treatment(s) you have received thus far:
|
|
|
Hip MRI?
|
Date and name of facility?
|
|
Physical Therapy (Hip)?
|
Did this treatment help?
|
|
How many sessions?
|
|
|
Hip Injection(s)
|
Did this treatment help?
|
|
How many and date of last injection?
|
|
|
Other Treatments (Hip)
|
Comment
|
|
Did this treatment help?
|
|
|
Foot and Ankle History
|
New Short Text Field
|
|
Which foot/ankle is symptomatic?
|
If both, which one hurts more?
|
|
What types of symptoms are you having?
• • •
|
What caused your symptoms?
|
|
When did your symptoms begin?
|
Have your symptoms been:
|
|
Are you taking any medications for your symptoms?
|
Is so, what medication (with dosage and frequency)?
|
|
Have you injured the symptomatic foot/ankle in the past?
|
If so, when did it occur and what was the diagnosis?
|
|
Please indicate all formal treatment(s) you have received thus far:
|
|
|
Foot/Ankle MRI?
|
Date and name of facility?
|
|
Physical Therapy (Foot/Ankle)?
|
Did this treatment help?
|
|
How many session?
|
|
|
Foot/Ankle Injection(s)
|
Did this treatment help?
|
|
How many and date of last injection?
|
|
|
Other Treatments (Foot/Ankle)
|
Comment
|
|
Did this treatment help?
|
|
|
Elbow History
|
New Short Text Field
|
|
Dominant Arm?
|
Which elbow is symptomatic?
|
|
If both, which one hurts more?
|
What type of elbow symptoms are you having?
• • •
|
|
What caused your pain?
|
When did your symptoms begin?
|
|
Have your symptoms been:
|
Does your elbow hurt:
|
|
Are you taking any medications for your symptoms?
|
Is so, what medication (with dosage and frequency)?
|
|
Have you injured the symptomatic elbow in the past?
|
If so, when did it occur and what was the diagnosis?
|
|
Please indicate all formal treatment(s) you have received thus far:
|
|
|
Elbow MRI?
|
Date and name of facility?
|
|
Physical Therapy (Elbow)?
|
Did this treatment help?
|
|
How many sessions?
|
|
|
Cortisone Injection(s) (Elbow)
|
Did this treatment help?
|
|
How many and date of last injection?
|
|
|
Other Treatments (Elbow)
|
Comment
|
|
Did this treatment help?
|
|
|
Review of Systems
• • •
|
|
|
Medical/Surgical History
|
New Short Text Field
|
|
Who referred you to the office today?
|
Primary Care Doctor Name
|
|
Pharmacy Name/Address
|
Pharmacy Phone Number
|
|
Past Medical History
• • •
|
Other Past Medical History
|
|
Past Surgical History (and dates)
|
|
|
Family Medical History
|
New Short Text Field
|
|
What medical conditions run in your family?
• • •
|
Additional Family Medical History
|
|
Occupational/Social History
|
New Short Text Field
|
|
Tobacco Use
|
Alcohol (drinks per week)
|
|
Caffeine (drinks per day)
|
Drug Use
|
|
Occupation
|
Employer
|
|
Medications and Allergies
|
New Short Text Field
|
|
Medications
|
Allergies (and reaction)
|
|
Vitals Signs
|
New Short Text Field
|
|
Height
|
Weight
|
