Shoulder Injury Form Fill in this form if you are suffering from shoulder pain. Shoulder 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 shoulder is in pain?*LeftRightBothBoth, left more than rightBoth, right more than leftPost an 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 exact area of pain in the shoulder?*What do you think started the pain?*How long have you had this current pain?*You will have an opportunity to discuss previous episodes of this pain later on. Just focus on this current episode.Is it constant or does it come and go?*ConstantCome and goOtherHas the pain changed since it started?* Better Same Worse Other If worse, describe.*If other, describe.*INTENSITY OF THE PAINOn a good day, pain out of 10?*012345678910On a bad day, pain out of 10?*012345678910Do you have trouble sleeping at night because of the pain?* Yes No If yes, describe.*Any pins and needles or numbness in your arms?* Yes No If yes, describe.* 24 HOUR BEHAVIOURDoes the pain change throughout the day?* Yes No E.g. stiff in the morning, improves over the day, sore at the end of the day.If yes, describe.*If no, describe.*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?INVESTIGATIONSHave you had any investigations on your shoulder?* Yes No E.g. XRAYS, MRI, CT SCANS or any other TESTS? (You will have an opportunity to attach these later on)If yes, describe.* GENRAL HEALTHHow would you describe your general health?* Good Ok Poor Other If other, use one word to describe.*Any current medical conditions?* Yes No If yes, describe.*Any past medical conditions?* Yes No If yes, describe.*Have you had any unexplained weightloss, loss of appetite or history of steroid use?* Yes No If yes, describe.*Have you had any night sweats?* Yes No If yes, describe.*Do you take any regular medications?* Yes No If yes, describe.*Have you taken any medications for this problem?* Yes No If yes, describe.*Lifestyle FactorsWhat is your occupation?*What is involved physically?How often do you exercise?* I don't exercise regularly. 1-2 times per week 3-5 times per week 7 times per week Other If other, describe how often and the type of exercise.*What type of exercise do you do?*Has this injury affected your work?* Yes No If yes, describe.*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. 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