Musculoskeletal Condition Form

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

Which side is affected?
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Rows Left Side Right Side Both Sides
Pain or Discomfort 1 2 3
Swelling / Inflammation 4 5 6
Redness / Bruising 7 8 9
Numbness, tingling or radiating signs 10 11 12
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?
Can you extend your neck and look up without producing your symptoms?
Can you bend your neck to the LEFT without producing your symptoms?
Can you bend your neck to the RIGHT without producing your symptoms?
Can you rotate your head to the LEFT without producing your symptoms?
Can you rotate your head to the RIGHT without producing your symptoms?
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:

Rows	Left Side	Right Side	Both Sides
Pain or Discomfort	1	2	3
Swelling / Inflammation	4	5	6
Redness / Bruising	7	8	9
Numbness, tingling or radiating signs	10	11	12

Which part is affected?
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Rows Front part Side part Back part Top shoulder Whole shoulder
Pain or Discomfort 13 14 15 16 17
Swelling / Inflammation 18 19 20 21 22
Redness / Bruising 23 24 25 26 27
Numbness, tingling or radiating signs 28 29 30 31 32
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:

Rows	Front part	Side part	Back part	Top shoulder	Whole shoulder
Pain or Discomfort	13	14	15	16	17
Swelling / Inflammation	18	19	20	21	22
Redness / Bruising	23	24	25	26	27
Numbness, tingling or radiating signs	28	29	30	31	32

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

Please tick all that apply:

Rows	Medial side, close to the body	Lateral side, away from the body	Back portion	Whole elbow
Pain or Discomfort	33	34	35	36
Swelling / Inflammation	37	38	39	40
Redness / Bruising	41	42	43	44
Numbness, tingling or radiating signs	45	46	47	48

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?
Can you straighten your elbow/s fully without pain/discomfort/difficulty?
With elbows straight, can you flex your wrist without pain?
With elbows straight, can you extend your wrist without pain?
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:

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:
Rows 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?
Can you spread your fingers out without pain/discomfort/difficulty?
Can you flex your wrist without pain/discomfort/difficulty?
Can you extend your wrist without pain/discomfort/difficulty?
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:

Which part is affected? Tick all that apply.
Rows Left Side Center Right Side Both Sides
Upper Back 61 62 63 64
Mid Back 65 66 67 68
Lower Back 69 70 71 72
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Pain or Discomfort
Rows Left Side Center Right Side Both Sides
Upper Back 73 74 75 76
Mid Back 77 78 79 80
Lower Back 81 82 83 84
Numbness, tingling or radiating signs
Rows Left Side Center Right Side Both Sides
Upper Back 85 86 87 88
Mid Back 89 90 91 92
Lower Back 93 94 95 96
To Buttocks
97 98 99 100
To Thighs
101 102 103 104
To Lower Leg/Calves 105 106 107 108
To Feet 109 110 111 112
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
Rows Left Side Center Right Side Both Sides
Upper Back 113 114 115 116
Mid Back 117 118 119 120
Lower Back 121 122 123 124
Do these symptoms wake you or keep you awake at night?
Other signs & symptoms you may have:
e.g. snapping, clicking
MOVEMENT
Can you squat down without producing the familiar symptoms?
Can you bend your trunk forward without producing the familiar symptoms?
Can you bend your trunk on each side without producing the familiar symptoms?
Can you extend your trunk backwards without producing the familiar symptoms?
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:

Rows	Left Side	Center	Right Side	Both Sides
Upper Back	61	62	63	64
Mid Back	65	66	67	68
Lower Back	69	70	71	72

Rows	Left Side	Center	Right Side	Both Sides
Upper Back	73	74	75	76
Mid Back	77	78	79	80
Lower Back	81	82	83	84

Rows	Left Side	Center	Right Side	Both Sides
Upper Back	85	86	87	88
Mid Back	89	90	91	92
Lower Back	93	94	95	96
To Buttocks	97	98	99	100
To Thighs	101	102	103	104
To Lower Leg/Calves	105	106	107	108
To Feet	109	110	111	112

Rows	Left Side	Center	Right Side	Both Sides
Upper Back	113	114	115	116
Mid Back	117	118	119	120
Lower Back	121	122	123	124

Which side is affected?
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Rows 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:

Which side is affected?
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Rows 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?
Can you bend your knee/s without difficulty or producing your symptoms?
Can you straighten your knee/s without difficulty or 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:

Which part is affected? Tick all that apply.
Rows Left Side Right Side Both Sides
Lower Leg 149 150 151
Ankle 152 153 154
Foot 155 156 157
Toes 158 159 160
If toes, please specify:
e.g. right little toe
When did this problem start?
SIGNS AND SYMPTOMS
Please tick all that apply:
Rows Left side
Right side Both sides
Pain or Discomfort
161 162 163
Swelling / Inflammation
164 165 166
Redness, bruising or discoloration
167 168 169
Numbness, tingling or radiating signs 170 171 172
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?
Can you stand on your heels without difficulty or producing your symptoms?
Can you curl your toes without difficulty or producing your symptoms?
Can you fan your toes out without difficulty or producing your symptoms?
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:

Rows	Left Side	Right Side	Both Sides
Lower Leg	149	150	151
Ankle	152	153	154
Foot	155	156	157
Toes	158	159	160

Rows	Left side	Right side	Both sides
Pain or Discomfort	161	162	163
Swelling / Inflammation	164	165	166
Redness, bruising or discoloration	167	168	169
Numbness, tingling or radiating signs	170	171	172

If you have concerns not listed above, please describe them here:
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