Dr. Hwang'S Shoulder Intake Form
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21901 CONNECTICUT AVE. S
SARTELL, MN 56377
MAIN 320-259-4100
FAX 320-259-8044
DR. HWANG’S SHOULDER INTAKE FORM
Patient Name:______________________________________ Date of Service:_________________ Age:____________
Patient Chart#_____________________________________ Referring Physician:_______________________________
1.
What side? (check one)
RIGHT
LEFT
BOTH
_________ BP
2.
What is your dominant side?
RIGHT
LEFT
AMBIDEXTROUS
_________ Height
3.
When did your shoulder pain start? (date)
______/_____/______
_________ Weight
4.
Is your shoulder pain due to an injury?
YES
NO
Y
N Previous
5.
If there wasn’t an injury, was the onset sudden?
YES
NO
Imaging
6.
Please briefly describe the injury or what brought this shoulder pain on.
7.
If you have had other shoulder injuries or shoulder surgeries, please describe.
Shoulder Injury:
Shoulder Surgery:
8.
If your shoulder is unstable how many times have you dislocated? ________ Last dislocation?___________________
9.
Where is the shoulder pain located? (check all that apply)
FRONT /
BACK /
SIDE /
TOP /
ARM /
DEEP /
SHOULDER BLADE /
NECK /
OTHER:________________________________________________________________________________
10. Please rate the severity on a scale from 0 to 10:
NOW: ____________
AT ITS WORST: ____________
11. Describe the quality of the pain. (check all that apply)
DULL
ACHY
SHARP
BURNING
TINGLING
THROBBING
OTHER:____________
12. Is the pain constant or intermittent?
CONSTANT
INTERMITTENT
13. Is the pain associated with any of the following? (check all that apply)
PAIN AT NIGHT -
SOUNDS -
CATCHING -
LOSS OF MOTION -
NECK OR BACK PAIN -
WEAKNESS -
PAIN RADIATING UP OR DOWN –
OTHER:____________________________
14. Does anything make it better? (check all that apply)
ICE -
REST -
ELEVATION -
COMPRESSION -
MEDICINE -
OTHER:_____________
15. What makes it worse? (check all that apply)
OVERHEAD ACTIVITY –
LIFTING –
REACHING BEHIND –
REACHING OUTWARD –
REACHING ACROSS –
OTHER:_________________________________
16. Do you have swelling?
YES
NO If yes, where?______________________________________________
17. Do you have numbness or tingling?
YES
NO If yes, where?_______________________________________
18. What have you tried for previous treatments? (check all that apply)
ORAL OR TOPICAL MEDICATIONS –
ICE –
HEAT –
PHYSICAL THERAPY –
BRACING –
INJECTIONS –
OTHER:____________________________________
19. If you have had physical therapy for your shoulder, where did you have it?___________________________________
What was done at physical therapy? (check all that apply)
STRETCHING –
STRENGTHENING –
ULTRASOUND –
IONTOPHORESIS –
OTHER:___________________________________________
20. Employment? _________________________________________________________________________________
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