Elbow/Forearm Injury Form Fill in this form if you are suffering from elbow/forearm pain. Elbow/Forearm Injury Form Step 1 of 5 20% Package* Initial Video Consultation Total $ 0.00 BASIC INFOName* First Name Surname Email* Enter Email Confirm Email Mobile Phone*e.g. +61_ _ _- _ _ _ - _ _ _ Date of Birth* DD slash MM slash YYYY Nationality* Which country do you live in?*Select CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweStreet Address Suburb* State*Select StateAshmore and Cartier IslandsAustralian Antarctic TerritoryAustralian Capital TerritoryChristmas IslandCocos (Keeling) IslandsCoral Sea IslandsHeard Island and McDonald IslandsJervis Bay TerritoryNew South WalesNorfolk IslandNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaPost Code* Height Weight Do you have a preference on which physiotherapist you would like?* Samuel Ward Bernie Chau Steph Alberts No Preference THE MAIN PROBLEMWhich elbow is the pain?*LeftRightBothBoth, left more than rightBoth, right more than leftOtherIf other, describe.*Post and image of you pointing to the area of pain.Accepted file types: jpg, jpeg, png, gif.While dressed point to the area of pain. This is not mandatory. Just be extra specific below if you don't. Where is the location of the pain in your elbow/forearm ?*Are you left or right handed?* Left Right What do you think cause the pain to start?*How long have you had this current pain?* Is it constant or does it come and go?*ConstantIntermittentOtherIf other, describe.*Has the pain changed since it started?* Same Better Worse Other If worse, describe.*If other, describe.*INTENSITY OF THE PAINOn a Good Day, Paint out of 10?*012345678910On a bad day, Pain out of 10?*012345678910Any pins and needles or numbness in your arms?* Yes No If yes, describe.*What Increases or causes the pain in your elbow or forearm?* Using your computer Getting dressed Opening Jars/Turning Taps Shaking Hands Carrying Things Computer Use Carrying a Plate Writing Putting weight through you arm Other Tick if applicableIf other, list.* Easing FactorsDoes anything reduce your pain?* Nothing Stretches Rest from use Massage Gentle Movement Ice Pack Other If other, describe.*24 HOUR BEHAVIOURDo you have trouble sleeping at night because of the pain?* Yes No If yes describe.* Does the pain change throughout the day?*(E.g. stiff in the morning, improves over the day or sore at the end of the day)PREVIOUS HISTORYHave you had this pain before?* Yes No If yes, describe.*How long ago was it? What treatment did you have? How long did it take to recover?Have you tried any other treatments for your current pain?* Yes No If yes, describe*INVESTIGATIONSHave you had any investigations on your elbow/forearm pain?* Yes No (Eg. XRAYS, MRI, CT SCANS or any other TESTS?) (You will have an opportunity to attach these later on)If yes, what have you had done?* GENRAL HEALTHHow would you describe your general health?* Good Ok Poor Other If other, use one word to describe.* Do you have any medical conditions?* Yes No If yes, list.*Have you had any unexplained weightloss, loss of appetite or history of steroid use?* Yes No If yes, please specify*Have you had any night sweats?* Yes No If yes, describe.*Do you take any regular medications?* Yes No If yes, list.*Have you taken any medications for this problem?* Yes No If yes, list.*Lifestyle FactorsWhat is your occupation?*Has this injury affected your work?* Yes No If yes, describe.*How often do you exercise?* I don't exercise 1-2 times per week. 3-5 times per week. 7 times per week. Other If other, describe.*What type of exercise do you do?*Has this injury affected your exercise or hobbies?* Yes No If yes, describe.*ADDITIONAL INFORMATIONIf you have anything else to add please mention it here.Attach any documents that you may feel are relevant here.Max. file size: 8 MB. Please read our terms... Terms & Conditions and Privacy Policy Note* I have read and agree to the Terms & Conditions and Privacy Policy
