Patient Questionnaire Template - Upper Quarter And Cervical Spine
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Patient Questionnaire - Upper Quarter
Date: ______________
(Please be thorough and fill out all that is applicable)
Patient (print): _________________________________ Date of Birth: _____________ Age: ________
Date of Injury or Onset of Symptoms: _____________
Return to Doctor Appointment: ___________
Date of Surgery: ______________
Type of Surgery: _____________________________________
Please provide a brief history of your present condition and how did this begin: _________________
______________________________________________________________________________________
Your primary concern/chief complaint about your CURRENT condition: _________________________
______________________________________________________________________________________
CURRENT Limitations of Function — Check ALL areas you ARE CURRENTLY LIMITED:
❑ Self Care: Cooking, Shopping, Cleaning
❑ Mobility: Walking & Moving Around
❑ Changing & Maintaining Body Position
❑ Carrying, Moving & Handling Objects
CURRENT Level of Function — (% of your normal ability): ❑ 0% (unable to care for self)
❑ 10%
❑ 25%
❑ 50%
❑ 75%
❑ 100%
❑ Other: ___%
Pain Location: (be specific): ❑ Left ❑ Right ❑ Both: __________________________________________
______________________________________________________________________________________
What is the intensity of your PRIMARY SOURCE OF PAIN (i.e., why you are beginning Hand
Therapy)?
0 = None
5 = Moderate
10 = Extreme
Circle your pain at its’ LOWEST:
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10
Circle the pain you have RIGHT NOW:
0
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10
Circle your pain at its’ HIGHEST:
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10
Describe your pain — Check ALL areas that apply:
❑ Burning
❑ Sharp
❑ Numbness/Tingling
❑ Throbbing
❑ Shooting
❑ Dull/Achy
❑ Other(s), Describe: ________________
❑ If numbness, tingling, and/or shooting where does the pain START and END? __________________
____________________________________________________________________________________
What aggravates your pain — Check ALL areas that INCREASE(S) your pain:
❑ Sitting
❑ Standing
❑ Sit-to-Stand
❑ Bending
❑ Walking
❑ Going to the Restroom ❑ Coughing/Sneezing ❑ Lying Down
❑ Driving
❑ Lifting/Carrying
❑ Other(s), Describe: __________________________________________________________________
What can you do to decrease your pain — Check ALL areas that DECREASE(S) your pain:
❑ Sitting
❑ Standing
❑ Walking
❑ When Still
❑ Mornings ❑ Evenings
❑ Lying Down
❑ Movement: Describe: _________________________________________________
❑ Other(s), Describe: __________________________________________________________________
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