Musculoskeletal Condition Form
Please answer the following questions as accurate as possible. Thank you!
Name:*
First Name Last Name
Age:*
Occupation:*
Hobbies:*
Answer all the regions you may have trouble with:

Neck
Which side is affected?
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Left Side Right Side Both Sides
Pain or Discomfort
Swelling / Inflammation
Redness / Bruising
Numbness, tingling or radiating signs
On a scale of 1 to 10, what was your worst pain level since the problem occurred?
1 2 3 4 5 6 7 8 9 10
1 is Barely noticeable, 10 is Worst pain ever! I could go to the Emergency
Is the pain / discomfort constant or intermittent?
Others:
e.g. clicking
MOVEMENT
Can you bend your neck forward and look down without producing your symptoms?
Yes No
Can you extend your neck and look up without producing your symptoms?
Yes No
Can you bend your neck to the LEFT without producing your symptoms?
Yes No
Can you bend your neck to the RIGHT without producing your symptoms?
Yes No
Can you rotate your head to the LEFT without producing your symptoms?
Yes No
Can you rotate your head to the RIGHT without producing your symptoms?
Yes No
What movements/activities INCREASE the signs and symptoms?
e.g. lying down on one side
What movements/activities INCREASE the signs and symptoms?
e.g. lying flat supine
If you have consulted a medical professional, please specify your diagnosis:

Shoulders
Which part is affected?
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Front part Side part Back part Top shoulder Whole shoulder
Pain or Discomfort
Swelling / Inflammation
Redness / Bruising
Numbness, tingling or radiating signs
On a scale of 1 to 10, what was your worst pain level since the problem occurred?
1 2 3 4 5 6 7 8 9 10
1 is Barely noticeable, 10 is Worst pain ever! I could go to the Emergency
Is the pain / discomfort constant or intermittent?
Others:
e.g. clicking, popping
MOVEMENT
Can you lift your arm/s overhead?
Can you reach the opposite shoulder without pain/discomfort/difficulty?
What movements/activities INCREASE the signs & symptoms?
e.g. brushing hair, donning on or off clothes
What movements/activities DECREASE the signs & symptoms?
e.g. supporting your arm, lying down
If you have consulted a medical professional, please specify your diagnosis:

Elbows
Which elbow is affected?
When did this problem start?
SIGNS AND SYMPTOMS

Please tick all that apply:

	Medial side, close to the body	Lateral side, away from the body	Back portion	Whole elbow
Pain or Discomfort
Swelling / Inflammation
Redness / Bruising
Numbness, tingling or radiating signs

On a scale of 1 to 10, what was your worst pain level since the problem occurred?
1 2 3 4 5 6 7 8 9 10
1 is Barely noticeable, 10 is Worst pain ever! I could go to the Emergency
Is the pain / discomfort constant or intermittent?
Others:
e.g. twisting, popping
MOVEMENT
Can you bend your elbow/s fully without pain/discomfort/difficulty?
Yes No
Can you straighten your elbow/s fully without pain/discomfort/difficulty?
Yes No
With elbows straight, can you flex your wrist without pain?
Yes No
With elbows straight, can you extend your wrist without pain?
Yes No
What movements/activities INCREASE the signs & symptoms?
e.g. forceful gripping, holding a glass
What movements/activities DECREASE the signs & symptoms?
e.g. supporting your elbow
If you have consulted a medical professional, please specify your diagnosis:

Forearm, Wrist and Hand
Which side is affected?
If fingers, please specify:
e.g. right pointer finger
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Left side
Right side Both sides
Pain or Discomfort

Swelling / Inflammation

Redness / Bruising

Numbness, tingling or radiating signs
On a scale of 1 to 10, what was your worst pain level since the problem occurred?
1 2 3 4 5 6 7 8 9 10
1 is Barely noticeable, 10 is Worst pain ever! I could go to the Emergency
Is the pain / discomfort constant or intermittent?
Others:
e.g. twisting, clicking
MOVEMENT
Can you make a fist without pain/discomfort/difficulty?
Yes No
Can you spread your fingers out without pain/discomfort/difficulty?
Yes No
Can you flex your wrist without pain/discomfort/difficulty?
Yes No
Can you extend your wrist without pain/discomfort/difficulty?
Yes No
What movements/activities INCREASE the signs & symptoms?
e.g. opening a jar, closing a bottle cap
What movements/activities DECREASE the signs & symptoms?
e.g. supporting your hand or wrist
If you have consulted a medical professional, please specify your diagnosis:

Back
Which part is affected? Tick all that apply.
Left Side Center Right Side Both Sides
Upper Back
Mid Back
Lower Back
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Pain or Discomfort
Left Side Center Right Side Both Sides
Upper Back
Mid Back
Lower Back
Numbness, tingling or radiating signs
Left Side Center Right Side Both Sides
Upper Back
Mid Back
Lower Back
To Buttocks

To Thighs

To Lower Leg/Calves
To Feet
On a scale of 1 to 10, what was your worst pain level since the problem occurred?
1 2 3 4 5 6 7 8 9 10
1 is Barely noticeable, 10 is Worst pain ever! I could go to the Emergency
Is the pain / discomfort constant or intermittent?
Redness, Bruising or Discoloration
Left Side Center Right Side Both Sides
Upper Back
Mid Back
Lower Back
Do these symptoms wake you or keep you awake at night?
Yes, always Yes, sometimes No, not at all
Other signs & symptoms you may have:
e.g. snapping, clicking
MOVEMENT
Can you squat down without producing the familiar symptoms?
Yes No
Can you bend your trunk forward without producing the familiar symptoms?
Yes No
Can you bend your trunk on each side without producing the familiar symptoms?
Yes No
Can you extend your trunk backwards without producing the familiar symptoms?
Yes No
What movements/activities INCREASE the signs & symptoms?
e.g. laughing, sneezing, straining, walking too long, sitting too long
What movements/activities DECREASE the signs & symptoms?
e.g. lying down, sitting down
If you have consulted a medical professional, please specify your diagnosis:

Hips
Which side is affected?
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Left side
Right side Both sides
Pain or Discomfort

Swelling / Inflammation

Redness, bruising or discoloration

Numbness, tingling or radiating signs
On a scale of 1 to 10, what was your worst pain level since the problem occurred?
1 2 3 4 5 6 7 8 9 10
1 is Barely noticeable, 10 is Worst pain ever! I could go to the Emergency
Is the pain / discomfort constant or intermittent?
Others:
e.g. snapping, popping
MOVEMENT
Can you squat down without producing your symptoms?
Can you stand on one leg (right leg) without producing your symptoms?
Can you stand on one leg (left leg) without producing your symptoms?
What movements/activities INCREASE the signs and symptoms?
e.g. running, going up the stairs
What movements/activities DECREASE the signs and symptoms?
e.g. lying down with legs straight, sitting down
If you have consulted a medical professional, please specify your diagnosis:

Knees
Which side is affected?
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Left side
Right side Both sides
Pain or Discomfort

Swelling / Inflammation

Redness, bruising or discoloration

Numbness, tingling or radiating signs
On a scale of 1 to 10, what was your worst pain level since the problem occurred?
1 2 3 4 5 6 7 8 9 10
1 is Barely noticeable, 10 is Worst pain ever! I could go to the Emergency
Is the pain / discomfort constant or intermittent?
Others:
e.g. snapping, popping
MOVEMENT
Can you squat down without difficulty or producing your symptoms?
Yes No
Can you bend your knee/s without difficulty or producing your symptoms?
Yes No
Can you straighten your knee/s without difficulty or producing your symptoms?
Yes No
What movements/activities INCREASE the signs and symptoms?
e.g. running, going up the stairs
What movements/activities DECREASE the signs and symptoms?
e.g. lying down with legs straight, sitting down
If you have consulted a medical professional, please specify your diagnosis:

Lower Leg, Ankle and Foot
Which part is affected? Tick all that apply.
Left Side Right Side Both Sides
Lower Leg
Ankle
Foot
Toes
If toes, please specify:
e.g. right little toe
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Left side
Right side Both sides
Pain or Discomfort

Swelling / Inflammation

Redness, bruising or discoloration

Numbness, tingling or radiating signs
On a scale of 1 to 10, what was your worst pain level since the problem occurred?
1 2 3 4 5 6 7 8 9 10
1 is Barely noticeable, 10 is Worst pain ever! I could go to the Emergency
Is the pain / discomfort constant or intermittent?
Others:
e.g. crepitus
MOVEMENT
Can you do some tiptoes without difficulty or producing your symptoms?
Yes No
Can you stand on your heels without difficulty or producing your symptoms?
Yes No
Can you curl your toes without difficulty or producing your symptoms?
Yes No
Can you fan your toes out without difficulty or producing your symptoms?
Yes No
What movements/activities INCREASE the signs and symptoms?
e.g. tiptoes, going up the stairs
What movements/activities DECREASE the signs and symptoms?
e.g. not putting weight on foot, sitting down
If you have consulted a medical professional, please specify your diagnosis:

SUBMIT
If you have concerns not listed above, please describe them here:
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Thank You!
Should be Empty:

	Left Side	Center	Right Side	Both Sides
Upper Back
Mid Back
Lower Back
To Buttocks
To Thighs
To Lower Leg/Calves
To Feet

	Left side	Right side	Both sides
Pain or Discomfort
Swelling / Inflammation
Redness, bruising or discoloration
Numbness, tingling or radiating signs

Musculoskeletal Condition Form