Shoulder History
Dr. Scott Gudeman
Please complete the front page AND back side of this page
Name: ______Today’s Date: ______
D.O.B.:______Age: ______Dominant Hand: R L
Referring Doctor (if none, leave blank): ______
Date of Injury (if no injury, when did problem begin?) ______
Occupation: ______
Which shoulder bothers you (circle one that applies):RightLeftBoth
Describe in detail how you injured this shoulder or specifically explain how this shoulder problem began: ______
Do you have any major medical problems (if so what are they)? ______
Shoulder problem began (check all that apply):
___ Suddenly___ While at home___ During a motor vehicle accident
___ Gradually___ While at work___ After a motor vehicle accident
___ During Sports___ Unknown
Name(s) of other doctors treating this shoulder problem: ______
Are you having pain in your shoulder? (Circle correct answer) YesNo
How bad is your pain today (mark line)?
0 10
No pain at all Pain as bad as it can be
Mark where you pain is on this diagram: use an “X” for the location of the pain, use an to show radiation of pain.
Does your shoulder feel unstable (as if it is going to dislocate?)YesNo
How unstable is your shoulder (mark line)?
010
Very StableVery Unstable
CONTINUED…
Please check all associated symptoms:
YesNo
______Catching or locking
______Weakness
______Stiffness
______Increased pain during overhead activities
______Night pain that awakens you
______Previous problems with the same shoulder
If yes, describe ______
______Affects your job performance
If yes, describe ______
______Affects your past-time sports
If yes, describe ______
______Affects your activities of daily living
If yes, describe ______
Do you take pain medication (aspirin, Advil, Tylenol, etc.)?Yes No
Do you take narcotic pain medication (codeine or stronger)?YesNo
How many pills do you take each day (average)?______pills
Previous treatment has included (check all that apply):
___ Rest___ Ice/Heat___ Changing activity
___ Cortisone injection___ Physical Therapy___ Brace/sling
___ Taping___ Home exercises
___ Surgery (If so, describe the type of surgery: ______)
Previous testing has included (check all that apply):
___Bone Scan___CT scan___MRI
___ EMG___ Xrays___ MRI with arthrogram
Circle the number in the box that indicates you ability to do the following activities:
0 = Unable to do; 1 = Very difficult to do; 2 = Somewhat difficult; 3 = Not difficult
Activity / Right Arm / Left Arm1. Put on a coat / 0 1 2 3 / 0 1 2 3
2. Sleep on your painful or affected side / 0 1 2 3 / 0 1 2 3
3. Wash back/do up bra in back / 0 1 2 3 / 0 1 2 3
4. Manage Toileting / 0 1 2 3 / 0 1 2 3
5. Comb hair / 0 1 2 3 / 0 1 2 3
6. Reach a high shelf / 0 1 2 3 / 0 1 2 3
7. Lift 10 lbs above shoulder / 0 1 2 3 / 0 1 2 3
8. Throw a ball overhand / 0 1 2 3 / 0 1 2 3
9. Do usual work – list: / 0 1 2 3 / 0 1 2 3
10. Do usual sport – list: / 0 1 2 3 / 0 1 2 3
______
Patient SignatureDate
______
Scott D. Gudeman, M.D.Date