Elbow History

Name: ________________________________________________Date of Birth: ____________

Occupation: ______________________Social Security Number: ________________________

Which elbow is involved: (C One) Right Left Both

When did symptoms first appear? Date:________________________

How did symptoms occur? (Check one)Injury (what happened) ______________________________________________SpontaneousArm pain then elbow painNeck pain then elbow painOther

If injured, how did injury occur? (Check all that apply)Sports related (which sport) ___________________________________________Fall or direct injury to elbowMotor vehicle accidentInjury to neck or arm, and then elbow painOther (describe) ____________________________________________________

What treatment have you had? (Check all that apply)

Who evaluated pain? Name: ________________________________________________

Name: ________________________________________________

X-rays Date:________________________

Results:___________________________________________________

MRI or CAT scan Date:________________________

Results:__________________________________________

Past medications, for elbow (please list) _____________________________________________

_____________________________________________________________________________

Please list any anti-inflammatory mediations you currently take: _________________________

_____________________________________________________________________________

Are you taking any anti-spasm medication? es (If yes, please list)

_____________________________________________________________________________

Have you had physical therapy for your elbow? If yes, where? ___________________

Dates: From:____________________ To:____________________

Have you had any injections in your elbow? Dates:____________________

Please list any surgeries (Date & Type; i.e. arthroscopy, reconstruction)

Date Type

1.___________________ ____________________________________________

2.___________________ ____________________________________________

3.___________________ ____________________________________________

Today’s Date: ______________

No Y

es No Y

Page 2 Elbow History

Current Symptoms: _____________________________________________________________

_____________________________________________________________________________

What is the level of your pain? (Check one in each column)

Mild Dull No ache

Moderate Sharp (Knife-like) Intermittent ache

Severe Burning Constant ache

Where is the pain located? (Check all that apply)

Front of elbow

Back of elbow

Side of elbow

Neck

Arm

What makes the elbow pain worse? (Check all that apply)

Any use of the arm Sports only Any sleeping position

Any activity when hand is above shoulder level

Other_____________________________________________________________

What improves pain? (Check all that apply)

Physical therapy Injections Ice Heat Rest Surgery

Medication: Type_________________ Exercises: Type________________________

Other___________________________________________________________________

What are your functional limitations?

Unable to work

Unable to do work above elbow level – job is restricted

Unable to comb hair

Unable to perform in sports

Type of sports ____________________________________________________

Unable to dress completely (i.e. shirt, coat, bra, etc.)

Unable to perform heavy lifting only

Other_____________________________________________________________

Other bone or joint problems:

Pain, Where? ______________________________________________________

Swelling, Where? ___________________________________________________

Surgery? __________________________________________________________

Name_________________________________D.O.B__________

Please mark on the scale your level of pain for the area being surveyed only.

Please only make ONE mark.Please DO NOT associate a number with the scale (such as from 1 – 10 scale).

Please DO NOT mark a range.

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CORRECT

I DO NOT MY PAINHAVEANY -------------------------------------------------------------- COULD NOT

PAIN BEWORSE

INCORRECT

I DO NOT 6-7 MY PAINHAVEANY -------------------------------------------------------------- COULD NOT

PAIN BEWORSE

INCORRECT

I DO NOT MY PAINHAVEANY -------------------------------------------------------------- COULD NOT

PAIN BEWORSE

� EXAMPLES EXAMPLES EXAMPLES EXAMPLES EXAMPLES EXAMPLES�

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******************************************************************************************

PLEASE MARKYOUR PAIN LEVELBELOW.

I DO NOT MY PAINHAVEANY ----------------------------------------------------------------------- COULD NOT

PAIN BEWORSE Instructions: Using the space bar, move the cursor along the line, then type a lower case l in the location that corresponds to your pain level.

Name_________________________________D.O.B__________

ELBOW EVALUATION/COMPLICATION FORMPatient Information

SUBJECT LAST NAME FIRST NAME MI

SOCIAL SECURITY NUMBER SIDE DATE OF EXAM Weight lbs SURGEON NAME- - _______________

Left Right MM DD YYASES PATIENT SELF EVALUATION

PLEASE HAVE PATIENT COMPLETE THIS PAGEPAIN

YES NO1. Are you having pain in your elbow? .....................................................................2. Do you have pain in your elbow at night? ............................................................3. Do you take pain medication (aspirin, Advil, Tylenol, etc.)?.................................4. Do you take narcotic pain medication (codeine or stronger)? .............................5. How many pills do you take each day (average)?6 On a scale from 0-10, how bad is your pain today? (check one)

(0 = No pain at all; 10 = Pain as bad as it can be.)

0 1 2 3 4 5 6 7 8 9 10

INSTABILITY1. Does your elbow feel unstable (as if it is going to dislocate)? Yes No2. On a scale from 0-10, how unstable is your elbow (check one)

(0 = Very stable; 10 = Very unstable.)

0 1 2 3 4 5 6 7 8 9 10

ACTIVITY OF DAILY LIVING (ADL)Indicate your ability to do the following activities: Unable Very Somewhat Not

to do difficult difficult difficult1. Put on a coat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Sleep on your painful or affected side. . . . . . . . . . . . . . . . . . . . . . . .

3. Wash back/fasten bra in back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Manage toiletting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Comb hair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6. Reach a high shelf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Lift 10 lbs. above elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8. Throw a ball overhand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. Do usual work (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10. Do usual sport (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Name_________________________________D.O.B__________

SF-36 Health SurveyPatient Information

Subject Last Name First Name MI

Social Security Number Today’s Date Surgeon Name

M M D D Y Y

INSTRUCTIONS:This survey asks for your views about your health. All information that you furnish will be held in strict confidence. Please

answer every question by filling in the appropriate response. If you are unsure about how to answer a question, please give thebest answer you can. Please do not leave a question blank. Mark all answers with an “X.”

1.) In general, would you say your health is: (Mark one response)Excellent Very Good Good Fair Poor

2.) Compared to one year ago, how would you rate your health in general now? (Mark one response)Much better now than one year ago Somewhat worse now than one year agoSomewhat better now than one year ago Much worse now than one year agoAbout the same now as one year ago

3.) The following questions are about activities you might do during a typical day. Does your health now limit you inthese activities? If so, how much? (Mark one response on each line)

a. Vigorous activities, such as running, lifting heavyobjects, participating in strenuous sports

b. Moderate activities, such as moving a table,pushing a vacuum cleaner, bowling, or playing golf

c. Lifting or carrying groceries

d. Climbing several flights of stairs

e. Climbing one flight of stairs

f. Bending, kneeling, or stooping

g. Walking more than a mile

h. Walking several blocks

i. Walking one block

j. Bathing or dressing yourself

a. Cut down on the amount of time you spent on work or other activities

b. Accomplished less than you would like

c. Were limited in the kind of work or other activitiesd. Had difficulty performing the work or other activities

(for example, it took extra effort)

YES,LimitedA Lot

YES,LimitedA Little

YES NO

No, NotLimitedAt All

4.) During the past 4 weeks, have you had any of the following problems with your work or other regular daily activitiesas a result of your physical health? (Mark one response on each line)

SF–36 Health Survey Continued Page 1 of 2

Name_________________________________D.O.B__________

5.) During the past 4 weeks, have you had any of the following with your work or other regular daily activities as aresult of any emotional problems (such as feeling depressed or anxious)? (Mark one response on each line)

10.) During the past 4 weeks, how much of the time has your physical health or emotional problems interfered withyour social activities (like visiting with friends, relatives, etc.)? (Mark one response)

All of the time Most of the time Some of the time A little of the time None of the time

11.) How TRUE or FALSE is each of the statements for you? (Mark one response on each line)

6.) During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normalsocial activities with family, friends, neighbors, or groups? (Mark one response)

Not at all Slightly Moderately Quite a bit Extremely

7.) How much bodily pain have you had during the past 4 weeks? (Mark one response)None Very Mild Mild Moderate Severe Very Severe

8.) During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the homeand housework)? (Mark one response)

Not at all A little bit Moderately Quite a bit Extremely

9.) These questions are about how you feel and how things have been with you during the past 4 weeks. For eachquestion, please give the one answer that comes closet to the way you have been feeling. (Mark one response oneach line)

How much of the time during thepast 4 weeks –

a. Cut down the amount of time you spent on work or other activitiesa. Accomplished less than you would likea. Didn’t do work or other activities as carefully as usual

YES NO

All OfThe Time

Most OfThe Time

A Good BitOf The Time

Some OfThe Time

A Little OfThe Time

None OfThe Time

DefinitelyTRUE

MostlyTRUE

Don’tKnow

MostlyFALSE

DefinitelyFALSE

a. Did you feel full of pep?

b. Have you been a very nervous person?

d. Have you felt calm and peaceful

e. Did you have a lot of energy?

f. Have you felt downhearted and blue?

g. Did you feel worn out?

h. Have you been a happy person?

i. Did you feel tired?

c. Have you felt so down in the dumps that nothingcould cheer you up?

End of SF–36 Health Survey Page 2 of 2

a. I seem to get sick a little easier than other peopleb. I am as healthy as anybody I knowc. I expect my health to get worsed. My health is excellent

Name_________________________________D.O.B__________