Chapman Upper Extremity Survey - Abilene Physical Therapy & Sports Rehab

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Upper Extremity Pre-Exam Form
Chapman Location

For patients experiencing pain/injury in any part of the upper extremity: shoulder, elbow, wrist, hand, or upper and lower arm. Please complete to the best of your ability and submit.

* Indicates required field

Name *

First

Last

PLEASE RATE YOUR PAIN LEVEL WITH ACTIVITY *

0 - No Pain 1 - Minimal - hardly noticeable 2-Mild - aware of pain but don't pay attention to it 3-Uncomfortable - bothers me but I can ignore it 4-Moderate - Constantly aware but can continue most activities 5-Distracting - Constantly aware and keeping me from doing some activities 6 - Distressing - Constantly aware of pain and I give up many activities. 7-Unmanageable - In pain all the time and unable to do most activities 8-Intense - Pain is so severe that it is hard to think of anything else. Talking & listening are difficult 9-Severe - My pain is all I can think about. I can barely talk or move because of it. 10-Unable to Move - In bed and can't move due to my pain. I need to go to the emergency room.

Please rate your ability to do the following activities: *

1. OPEN A TIGHT OR NEW JAR *

No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable

2. DO HEAVY HOUSEHOLD CHORES (e.g. wash walls, floors) *

No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable

3. CARRY A SHOPPING BAG OR BRIEFCASE *

No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable

4. WASH YOUR BACK *

No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable

5. USE A KNIFE TO CUT FOOD *

No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable

6. RECREATIONAL ACTIVITIES IN WHICH YOU TAKE SOME FORCE OR IMPACT THROUGH YOUR ARM, SHOULDER OR HAND (e.g., golf, hammering, tennis, etc.) *

No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable

7. DURING THE PAST WEEK, TO WHAT EXTENT HAS YOUR ARM, SHOULDER OR HAND PROBLEM INTERFERED WITH YOUR NORMAL SOCIAL ACTIVITIES WITH FAMILY, FRIENDS, NEIGHBORS OR GROUPS? *

Not at all Slightly Moderately Quite a bit Extremely

8. DURING THE PAST WEEK, WERE YOU LIMITED IN YOUR WORK OR OTHER REGULAR DAILY ACTIVITIES AS A RESULT OF YOUR ARM, SHOULDER OR HAND PROBLEM? *

Not Limited At All Slightly Limited Moderately Limited Very Limited Unable

PLEASE RATE THE SEVERITY OF THE FOLLOWING SYMPTOMS IN THE LAST WEEK: *

9. ARM, SHOULDER OR HAND PAIN *

None Mild Moderate Severe Extreme

10. TINGLING (PINS AND NEEDLES) IN YOUR ARM, SHOULDER OR HAND. *

None Mild Moderate Severe Extreme

11. DURING THE PAST WEEK, HOW MUCH DIFFICULTY HAVE YOU HAD SLEEPING BECAUSE OF THE PAIN YOUR ARM, SHOULDER OR HAND? *

None Mild Moderate Severe Difficulty So Much Difficulty That I Can't Sleep

Submit

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.

Now With 2 Locations to Better Serve You!

103 Northwest 15th Street
Abilene, KS 67410
Phone: 785-263-3646
FAX: 785-263-3689

HOURS:
Monday - Friday
8:00 a.m - 5:00 p.m.

1030 North Marshall, Suite B
Chapman, KS 67431
Phone: 785-922-4016
FAX: 785-922-4018

HOURS:
Monday - 1 p.m. - 5 p.m.
Tuesday & Thursday 8 a.m. - 5 p.m.

Contact Us

Home
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Therapy Services
Other Services
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Direct Access
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