Shoulder

• Date / MM / DD YYYY

  ---

• Referred by to

• Patient Name Title First Last Suffix

• DOB / MM / DD YYYY

  ---

• Address
  Street Address Address Line 2 City Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missourri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming State   Postal / Zip Code

  ---

• Phone - ### - ### ####

  Phone 2 - ### - ### ####

  Email e.g. jsmith@example.com

• Date of Onset / MM / DD YYYY Place of Injury Auto School Work N/A Other Other: Which Shoulder Left Right Both

  ---

• Sport Injury related

  Yes No
  If yes, describe sport

• How did the injury happen?

• Previous Patient Yes No Previous Injury Yes No ER Visit Yes No

• Previous Surgery Yes No If yes, has records Yes No Dr

• Previous Physician Visit Yes No Sx Recommendation Yes No N/A Dr

• Diagnostic Studies X-Ray MRI CT Scan N/A Studies in possession Yes No N/A Reports Yes No N/A

  ---

• Pain Scale 0 1 2 3 4 5 6 7 8 9 10

  ---

• Where does it hurt? Front Back Inside History of Dislocations/Subluxations Yes No Can you raise your arm up over your head Yes No Assistive Device

• Loss range of motion Yes No Numbness or tingling down the arm Yes No Any Discoloration Yes No

• Night Pain Yes No

  ---

• Additional Information*

  Please give us any additional information that may help us to help you.

  ---

•