Shoulder Pain Relief Intake Form
Please complete this form to help us assess your shoulder pain and provide the most effective relief options.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Intake
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which shoulder is affected?
*
Left
Right
Both
How would you rate your current shoulder pain?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
0 is No pain, 10 is Worst pain imaginable
Please indicate which activities make your shoulder pain worse (select all that apply):
Lifting objects
Reaching overhead
Sleeping on affected side
Driving
Other
When did your shoulder pain begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced any of the following symptoms? (Select all that apply)
Swelling
Numbness or tingling
Weakness
Limited range of motion
Other
Have you had any previous treatments for your shoulder pain? If yes, please specify.
Please list any current medications and relevant medical conditions.
Signature (please sign below to confirm your consent)
*
Submit Intake Form
Submit Intake Form
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