Elbow Pain Questionnaire

Which elbow hurts? L R Both (please circle one)

How long has your elbow hurt? ________________________________

Did your elbow pain begin as the result of a specific accident or injury? _________

If yes, please describe briefly: __________________________________________

____________________________________________________________________

____________________________________________________________________

Was the onset of your elbow pain gradual? _____

Have you had previous surgery on your inured elbow? _______________________

Are you right-handed or left-handed? _____________________________________

Have you been treated with any of the following for your elbow pain:

_____Physical Therapy

_____Anti-inflammatory medication

_____Injections to the elbow

_____Steroid medications

_____Braces or splints

Where is the pain in your elbow? _____ Front _____Back _____ Outer side

_____Inner side _____Other

To what degree do you experience pain:

Does it cause increased pain to throw a ball? ______________________________

Can you lift a gallon of milk straight ahead to neck level? ____________________

Can you comb your hair? ______________________________________________

_________________________________

FOR PHYSICIAN USE

AROM: Flexion_____ Extension_____ ER at 90_____ IR at 90_____

PROM: Flexion_____ Extension_____ ER at 90_____ IR at 90_____

Tenderness on Exam: Medical_____ Lateral_____ Other_____

Effusion: Localized_____ Mild defused_____ Severe_____

If localized, where_________________________

Instability: Medical YES/NO Lateral YES/NO

Pronation/Superination Normal __________degrees decrease total arc