Elbow Injury Intake Form
Please provide details about your elbow injury to help us with your assessment.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Injury
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Which elbow is injured?
*
Left
Right
Both
How did the injury occur?
*
Please Select
Fall
Direct blow
Twisting injury
Sports accident
Work-related accident
Other
Rate your current pain level
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Current symptoms (select all that apply)
*
Pain
Swelling
Bruising
Numbness or tingling
Limited movement
Weakness
Other
Is there visible swelling or bruising?
*
No
Swelling only
Bruising only
Both swelling and bruising
How is your range of motion or function affected?
*
Please Select
No limitation
Mild limitation
Moderate limitation
Severe limitation
Unable to move elbow
What immediate care have you taken?
*
None
Applied ice
Rested the elbow
Used a sling or support
Taken pain medication
Other
Additional notes or details
Submit
Should be Empty: