Initial (Pre-Surgery)

IDENTIFICATION


Name: *

RAMQ # *

Date of birth: *
 /  / 

Weight: *

Height: *

MEDICAL PROBLEMS


Brain

Heart

Lung

Kidney

Bowel

Infectious diseases

Endocrinology

Use of blood thinners

Psychiatric

Other medical problems (please describe):

Do you smoke?
If yes, number of cigarettes per day:

Do you drink regularly?
Number of drinks per week:

Do you engage in recreational drugs?
If yes, which ones and number of times per month:

Any cancers in the past?
If yes, what kind of cancer:
Treatment to date:

Any surgeries in the past?
If yes, name of surgery + side if applicable and date:

Allergies to medications:

List of medications taken:

WORK


Is this a CSST claim / SAAQ claim?

Job title:

Would you describe your job as

Work status: do you work right now?

If no (not working)

If yes (working)

PROBLEM AT HAND


Which part of the body hurts?

If top, specify:

If bottom, specify:

Date of beginning of symptoms (approximately):
 /  / 

Does the pain wake you up at night?
If yes, number of times per night / week / month on average:

Do you have pain at rest?

Have you received any treatments to date for this problem?


Pain amount when it hurts the least: 0 = no pain / 10 = extreme pain

Pain amount on average: 0 = no pain / 10 = extreme pain

Pain amount when it hurts the most: 0 = no pain / 10 = extreme pain
Please rate your ability to do the following activities in the last week:

1. Open a tight new jar.

2. Do household chores (e.g. wash walls, floors).

3. Carry a shopping bag or briefcase.

4. Wash your back.

5. Use a knife to cut food.

6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).

7. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours or groups?

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?

Please rate the severity of the following symptoms in the last week.


9. Arm, shoulder or hand pain.

10. Tingling (pins and needles) in your arm, shoulder or hand.

11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?

WORK MODULE (OPTIONAL)

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking if that is your main work role).

NOTE: If you do not work, you may skip this section.


Please indicate what your job / work is:

In the past week, did you have any difficulty doing the following:


Using your usual technique for your work?

Doing your usual work because of arm, shoulder or hand pain?

Doing your work as well as you would like?

Spending your usual amount of time doing your work?

SPORTS / PERFORMING ARTS MODULE (OPTIONAL)

The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which is most important to you.

NOTE: If you do not play a sport or an instrument you may skip this section.



Please indicate the sport or instrument which is most important to you:

In the past week, did you have any difficulty doing the following:


Using your usual technique for playing your instrument or sport?

Playing your musical instrument or sport because of arm, shoulder or hand pain?

Playing your musical instrument or sport as well as you would like?

Spending your usual amount of time practising or playing your instrument or sport?

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