UPPER EXTREMITY QUESTIONNAIRE
UPPER EXTREMITY QUESTIONNAIRE
NAME: __________________________________ DATE: ___________
Where are your symptoms? μ Right μ Left
μ SHOULDER μ UPPER ARM μ ELBOW μ FOREARM μ WRIST μ HAND
What area is affected? μ Inside μ Outside μ Front μ Back
Did you injure yourself recently? μ No μ Yes
If so, When? __________________________ How? _____________________________________
If no injury, How long have you had these problems? __________________________________
Have you had previous imaging studies of this area? If so, what study?
μ MRI μ CT Scan μ X-Rays μArthrogram μ Ultrasound μ Other ____________
If so, where?____________________________
Have you ever had surgery in this area? μ No μ Yes ______
If so, what? ____________________________________ when?________
Have you had any treatment or therapy? μ No μ Yes If so, when ______________________
What is your approximate weight? _________ lbs
Are you, or do you think you may be pregnant? μ No μ Yes
DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING ?
μ Pain μ Joint “giving out”
μ Numbness μ Weakness
μ Click μ Broken Bones
μ Swelling / Mass μ Other ________________
THANK YOU !
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