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Intake Form
Thank you for taking the time to complete this form and facilitate your care with us. Please fill out the form below and we will get back to you.
YOUR DETAILS
Title
Mr.
Mrs.
Ms.
First name
*
Last name
*
Date of birth
*
Email
*
Phone
*
Address
*
Have you ever been seen by Ms. Delaney before for this problem?
*
Yes
No
HISTORY OF PRESENT COMPLAINT/INJURY/ILLNESS
Injured side
*
Right
Left
Bilateral
Dominant side
*
Right handed
Left handed
Date problem began
*
Main complaint (explain your complaint in your own words)
*
Previous treatment for this condition? e.g. physio, anti-inflammatories, prior surgeries etc
*
Yes
No
Explain
Level of pain (0 = no pain & 10 = severe pain)
*
Select
0
1
2
3
4
5
6
7
8
9
10
If 100% is an entirely normal or perfect shoulder and 0% is a completely useless shoulder, what percentage would you rate your shoulder?
*
Timing of pain
Constant
Worse at night
Wakes from/prevents sleep
Worse in morning
Worse with activity
Have you had any imaging of your shoulder?
None
X-Ray
MRI
MRI Arthrogram (MRI with dye in joint)
CT
CT Arthrogram (CT with dye in joint)
PAST MEDICAL HISTORY / ONGOING MEDICAL ISSUES
Medical history
Surgical history
Medications and dosage
Drug/medicine allergies
Have you ever had any problems with anaesthesia?
Yes
No
What type of anaesthesia have you had problems with?
SOCIAL HISTORY
Occupation
*
Do you live alone?
*
Yes
No
If no, who lives with you?
Do you smoke?
*
Yes
No
If yes, how many cigarettes per day?
Have you ever smoked?
*
Yes
No
If yes, when did you quit?
Do you drink alcohol?
*
Yes
No
What is your average alcohol intake per week?
PROFESSIONAL AFFILIATIONS
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