ORTHOPAEDIC ELBOW PATIENT QUESTIONNAIRE ORTHOPAEDIC ELBOW PATIENT QUESTIONNAIRE Age: Gender: male female Your Height: ____' _____" Weight: _______ lbs Referring Doctor Information Primary Doctor Information Name: Name: Specialty: Specialty: City: State: City: State: History of Your Current Orthopaedic Problem Hand Dominance: Right Left Both The problem primarily involves: Shoulder R / L Elbow R / L (Check all that apply and circle side) Other ______________________________________________ How long has this been present? Since: ____/ ____/ ____ or For: _______ Days Months Years (dd / mm/ yy) What caused the problem to start? Unknown reason Accident ( Motor vehicle Fall) Did the problem start at work? No Yes Will (has) a worker's compensation claim be filed? No Yes How do you describe your pain? Aching Burning Sharp/ Stabbing Numbness/ Tingling No pain Other ______________________________________________ How severe is the problem? Mild Moderate Severe Is it getting better or worse? Better Same Worse Previous non-surgical treatments for this No previous treatment Physical Therapy Injections problem have included: Cast Brace Manipulation﹤ Other ______________________________________________ Describe any previous surgery for this problem below Doctor Dr.'s Specialty City, State Medications taken for this problem Name of Medication (s) Dose For how long Anti-inflammatories Narcotic pain relievers Other MR 1130 Rev 6/15 Page 1 of 4 ORTHOPAEDIC ELBOW PATIENT QUESTIONNAIRE MR 1130 Rev. 10/16 page 1 of 4 ORTHOPAEDIC ELBOW PATIENT QUESTIONNAIRE MUST HAVE AN OOS LABEL ON THE FRONT SIDE OF THIS FORM ORTHOPAEDIC ELBOW PATIENT QUESTIONNAIRE (2-SIDED FORMS MUST HAVE AN OOS LABEL ON BOTH SIDES) X-rays and tests for this problem Results Date Where Plain X-rays MRI CT Scan Bone Scan Other ____________________ Past Medical History Please check "yes" or "no" in each row. Yes No Heart disease Hypertension (high blood pressure) High cholesterol Stroke Lung disease (ie. asthma, COPD) Bowel disease Kidney disease Diabetes Alcoholism Anemia or blood disease Cancer Depression Liver disease Osteoarthritis, degenerative arthritis Rheumatoid arthritis Seizure disorder Ulcer or stomach disease Gastric reflux or hiatal hernia Blood clots (leg or lung) Other medical problems List: _______________________ Medications (other than those indicated previously) No other medications Medication Dose Reason for taking medication Are you allergic to any medication? Yes No If yes, please list medications: _________________________________________________________________ Past surgical history (other than those listed previously) No other surgery Operation Date Surgeon MR 1130 Rev 6/15 Page 2 of 4 ORTHOPAEDIC ELBOW PATIENT QUESTIONNAIRE MR 1130 Rev. 10/16 page 2 of 4 ORTHOPAEDIC ELBOW PATIENT QUESTIONNAIRE MUST HAVE AN OOS LABEL ON THE FRONT SIDE OF THIS FORM ORTHOPAEDIC ELBOW PATIENT QUESTIONNAIRE (2-SIDED FORMS MUST HAVE AN OOS LABEL ON BOTH SIDES) Family History (Check all that apply) None apply Heart disease Diabetes Cancer Osteoarthritis Rheumatoid arthritis Bleeding problems Other __________________ Social History Occupation: _______________________________ Married? Yes No Children? Yes No Do you smoke cigarettes? Yes No Quit _____ years ago Do you drink alcoholic beverages? Yes No If yes, how often? _______________ Please list your sports/recreation activities: Activity Level: Competitive Recreational Review of Systems Check all items that apply If no items on a line apply, check none None Fever Chills Weight loss Eyes - Reading glasses Change of vision Ears - Hearing loss Ear pain Vertigo Nose/ throat/ mouth - Nose bleeds Hoarseness Bleeding gums Tooth or gum trouble Lungs - Cough Shortness of breath Pneumonia Asthma Emphysema Stomach - Nausea Vomiting Stomach pain Ulcers Bowels - Frequent diarrhea Frequent constipation Urinary tract - Frequent or burning urination Blood in urine Heart - Chest pain Palpitations Abnormal heart beat Swollen ankles Skin - Rashes Skin ulcers Scars Dermatitis Brain - Seizures Frequent headaches Memory loss Blackouts Neuropathy or loss of feeling in hands or feet Blood - Bleeding Anemia Swollen lymph nodes Non-drug allergies - Allergies to foods Seasonal allergies Descriptions/ Other: ***** FOR OFFICE USE ONLY ***** ***** FOR OFFICE USE ONLY ***** Notes: Xrays ____ Shoulder – AP, Out, AK, IR/ER, AC ____ Elbow – AP, LAT, RC ____ C-Spine series Dx: Plan: Follow-Up - ____days _____wks _____mths ______prn Physician Signature ___________________________ Date _____________ MRMR 1130 1130 Rev. Rev 10/16 6/15 page Page 3 of 4 3 of 4 ORTHOPAEDICORTHOPAEDIC ELBOW ELBOW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE MUST HAVE AN OOS LABEL ON THE FRONT SIDE OF THIS FORM ORTHOPAEDIC ELBOW PATIENT QUESTIONNAIRE (2-SIDED FORMS MUST HAVE AN OOS LABEL ON BOTH SIDES) ROM Right Left Extension Flexion Pronation Supination SPECIAL TESTS Right Left Elbow Flexion __Yes __No __Yes __No __Yes __No Cubital Tinel __Yes __No Moving Valgus Stress __Yes __No __Yes __No __Yes __No Varus Laxity __Yes __No Pain with forced flexion __Yes __No __Yes __No __Yes __No Effusion __Yes __No __Yes __No Swelling __Yes __No __Post __Med __ECRB __RC ___other Tenderness __Post __Med __ECRB __RC ___other Patient or Parent/Guardian Signature Date Time Physician Signature Date Time MRMR 1130 1130 Rev.10/16 Rev 6/15 page 4Page of 4 4 of 4 ORTHOPAEDICORTHOPAEDIC ELBOWELBOW PATIENTPATIENT QUESTIONNAIREQUESTIONNAIRE .