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 Arm
1. 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