Upper Arm Injury Form Fill in this form if you are suffering from upper arm pain or anterior shoulder pain. Upper Arm 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 StateSelect 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 arm is the pain in?*LeftRightBothBoth, left more than rightBoth, right more than leftPost 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. What is the main area of pain?*What do you think started the pain?*How long have you had this current pain?*You will have an opportunity later on to discuss previous episodes of this pain. Just focus on the current episode here.Is it constant or does it come and go?ConstantCome and goOtherIf other, describe.*Has the pain changed since it started?* Better Same Worse Other If other, describe.*If worse, 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 BEHAVIOURDo you get night pain in this area?* Yes No If yes, describe.*Does the pain change throughout the days?* 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 upper arm?* 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/list.*Any past medical conditions?* Yes No If yes, describe/list.*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 physicallyHas this injury affected your work?* Yes No If yes, describe.*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 Pre InjuryIf other, what type of exercise and how often?*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. 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