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Please circle the answers below that BEST apply
*
Indicates required field
Patient ID#
*
Please rate your pain level with activity: (0= no pain; 10 = very severe pain
*
0
1
2
3
4
5
6
7
8
9
10
How satisfied are you with the level of care and service provided?
*
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Please rate your progress with functional activities from start of therapy to the point in time.
*
Excellent
Good
Fair
Poor
At this point in your treatment, have your therapy goals been met?
*
Completely Met
Mostly Met
Partially Met
Not Met
1. Open a tight or new jar
*
1 - No Difficulty
2 - Mild Difficulty
3 - Moderate Difficulty
4 - Severe Difficulty
5 - Unable
2. Do heavy household chores (eg. wash walls, floors)
*
1 - No Difficulty
2 - Mild Difficulty
3 - Moderate Difficulty
4 - Severe Difficulty
5 - Unable
3. Carry a shopping bag or briefcase
*
1 - No Difficulty
2 - Mild Difficulty
3 - Moderate Difficulty
4 - Severe Difficulty
5 - Unable
4. Wash your back
*
1 - no difficulty
2 - mild difficulty
3 - moderate difficulty
4 - severe difficulty
5 - unable
5. Use a knife to cut food
*
1 - no difficulty
2 - mild difficulty
3 - moderate difficulty
4 - severe difficulty
5 - unable
6. Recreational activites in which you take some force or impact through your arm, shoulder or hand ( eg, golf, hammering, tennis, etc)
*
1 - No difficulty
2 - mild difficulty
3 - moderate difficulty
4 - severe difficulty
5 - unable
7. During the past week, to what extent has your arm, shoulder, or hand problem interfered with ou normal social activities with family, friends, neighbors or groups
*
1 - not at all
2 - slightly
3 - moderately
4 - quite a bit
5 - extremely
8. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder, or hand problem
*
1 - not limited at all
2 - slightly limited
3 - moderately limited
4 - very limited
5 - unable
Below, please rate the severity of the following symptoms in the last week
9. Arm, shoulder, or hand pain
*
1 - none
2 - mild
3 - moderate
4 - severe
5 - extreme
10. Tingling (pins and needles) in your arm, shoulder, or hand
*
1 - none
2 - mild
3 - moderate
4 - severe
5 - extreme
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand?
*
1 - none
2 - mild
3 - moderate
4 - severe difficulty
5 - so much difficulty that i can't sleep
Submit
Home
Physical Therapy
INFO
>
Locations
ONTHEGO_CALENDAR
News
Blog
Staff
>
Marc Riley
Ben Schanbacher
Casey Swartz
Melissa Palmer
Intake forms
What to expect
Services