Shoulder Injury Form- PhysioWard Online injury forms

Save and Continue Later

BASIC INFO
Name*
First Name Surname
Email*
Enter Email Confirm Email
Mobile Phone*
e.g. +61_ _ _- _ _ _ - _ _ _
Date of Birth*
Date Format: DD slash MM slash YYYY
Nationality*
Which country do you live in?*
Street Address*
Suburb*
State*
Post Code*
Height
Weight
Do you have a preference on which physiotherapist you would like?*
- Samuel Ward
- Bernie Chau
- Steph Alberts
- No Preference

Save and Continue Later

THE MAIN PROBLEM
Which shoulder is in pain?*
Post an image of you pointing to the area of pain.
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?*
Has the pain changed since it started?*
- Better
- Same
- Worse
- Other
If worse, describe.*
If other, describe.*
INTENSITY OF THE PAIN
On a good day, pain out of 10?*
On a bad day, pain out of 10?*
Do 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.*

Save and Continue Later

24 HOUR BEHAVIOUR
Does 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 HISTORY
Have 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?
INVESTIGATIONS
Have 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.*

Save and Continue Later

Shoulder Injury Form