Patient Health Questionnaire

Your Full Name *  

 Sex *  

Height * (cm)

Weight * (kg)  

Date of Birth *

Your Contact Details

Email *

    Phone *

Address *  

    Country *  

Zip: *  

Occupation: *  

Job description:  

Name of your Medical Doctor *  

  Specialty   —Medical DoctorGeneral PractitionerOsteopathChiropractorPhysiotherapistHospitalistSurgeonCardiologistDermatologistEndocrinologistGastroenterologistObstetricianOtolaryngologistMassage TherapistCertified TrainerOther

Other doctors or therapists you have seen for this problem

  Specialty   —Medical DoctorGeneral PractitionerOsteopathChiropractorPhysiotherapistHospitalistSurgeonCardiologistDermatologistEndocrinologistGastroenterologistObstetricianOtolaryngologistMassage TherapistCertified TrainerOther

  Specialty   —Medical DoctorGeneral PractitionerOsteopathChiropractorPhysiotherapistHospitalistSurgeonCardiologistDermatologistEndocrinologistGastroenterologistObstetricianOtolaryngologistMassage TherapistCertified TrainerOther

Your Condition

We would need to get a bit more information to better understand your condition. Please answer the questions below so that we can see if your case is possible and advise you on best further steps.

Fields marked with * are required

Date of Onset

When were you first diagnosed with frozen shoulder?  

Current Situation

Is it getting worse? *  

Have you lost work time? *  

Does it interfere with your:     

Sleep? *  

Work? *  

Daily Routine? *  

Was it result of an accident?*   —Yes, car accidentYes, on the jobYesNo

IF it was result of an accident, please describe the circumstances that resulted your condition (otherwise skip this field)

Movability

Percentage of shoulder movability (Total: 0/100; numbers only) *

Right side: *

Left side: *

Past Diagnosis

Fields marked with * are required

Please write a brief history of the condition (from onset to current date including treatments and responses)

Have you ever been diagnosed or told you had any of the following? Please select yes or no for every question. If yes, please specify in “Comment” field.

High Blood Pressure (hypertension) *

Neck pain (Where?) *

Joint degeneration and/or Arthritis (if yes, please mention where) *

Haemophilia or other blood disease *

Diabetes (if yes, what type) *

Osteoporosis or Osteopenia *

Whiplash injury (flexion-extension injury) (cervical sprain) *

Numbness in the hands or fingers *

Have any of your relatives ever suffered a stroke *

Have you had cortisone shots? *

Do you take any medication on a regular basis? (e.g. Blood thinners) What? (Comidine, Heparin, Aspirin, Anti-hypertensive medicine, etc)

Do you have any allergies to medications?

Shoulder Pain and Disability Index (SPADI)

The Shoulder Pain and Disability Index (SPADI) is a self-administered questionnaire that consists of two dimensions, one for pain and the other for functional activities. The pain dimension consists of five questions regarding the severity of an individual’s pain. Functional activities are assessed with eight questions designed to measure the degree of difficulty an individual has with various activities of daily living that require upper-extremity use. The SPADI takes 5 to 10 minutes for a patient to complete and is the only reliable and valid region-specific measure for the shoulder. Source: Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res. 1991 Dec;4(4):143-9.

Pain scale: How severe is your pain?

How is pain at its worst? *

When lying on involved side? *

Reaching for something on a high shelf *  

Touching the back of your neck? *

Pushing with the involved arm? *

Pain scale: Disability Scale

Washing your hair? *

Washing your back? *

Putting on an undershirt or jumper? *

Putting on a shirt that buttons down the front? *  

Putting on your pants? *

Placing an object on a high shelf? *

Carrying a heavy object of 10 pounds (4,5 kg)? *

Removing something from your back pocket? *

DOCUMENTS

Our clinic staff would also need to receive and review few documents about your condition. Here you are able to upload the X-rays or MRI, pictures, videos or copies of your medical reports. If you are unable to extract the image files from CD/DVD received from your Clinic, please contact us.

NB! Before submitting files, please read the following:

• Please note the format and size of files accepted!
• Make sure your files have different filenames (for example: file1, file2 or neck1, shoulder1)!
• Please use low resolution/quality settings while filming or taking photos. We only need to see the range of movement.
• If you need to submit more files than there are upload slots, please zip the files. Need help on how to create a zip (compressed) file with many files or smaller size? Look here!
• With slower or unstable (wi-fi or mobile data) internet connection and (many) big video/image files (close to maximum size allowed), the form might take too long to submit and time-out (info will not be submitted).

Need help on how to create a zip (compressed) file with many files or smaller size? Look here!

Need to make your photos or reports smaller in size? You can use this option HERE!

1) X-Rays

X-rays of both your neck and your infected shoulder. * Shoulder: Anteroposterior, Internal and External rotation * Cervical: Obliques, Lateral, Anteroposterior
Accepted file formats & size: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mpg, jpg, jpeg, png. Size limit per file is 4mb. ONE file per field!

Need help on how to create a zip (compressed) file that contains many files? Look here

Right Shoulder (up to 4 mb)

Left Shoulder (up to 4 mb)

Neck (up to 4 mb)

2) Medical Reports & MRI

Medical reports is for review. MRI would be helpful, although is not necessary. Accepted file formats & size: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mpg, jpg, jpeg, png. Size limit per file is 4mb. ONE file per field!

Medical Report (up to 4 mb)

MRI (up to 4 mb)

3) Video & Photos

A short video or photos of your arm movement ability would be quite helpful in our assessment. Please see “3 Helpful Movements” document for instructions. Accepted file formats & size: pdf, rtf, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif, mov, wmv or rm. ONE file (up to 10 mb) per field!

Movement 1 (1 file up to 10 mb)  

Movement 2 (1 file up to 10 mb)  

Movement 3 (1 file up to 10 mb)  

Need help on how to create a zip (compressed, smaller size) file? Look here

—> ! Important notes:

! Please use low resolution/quality settings while filming or taking photos. We only need to see the range of movement.

! With slower or unstable internet connection and big video/image files (close or over to maximum size allowed), the form might take too long to submit and time-out (information will not be submitted).

+ If required fields are correctly filled and files are with right format and size, the data will be submitted shortly (depending on your connection and files attached it can take up to 1-2 minutes) and you will be redirected. You will also receive an email (please also check your spam/junk folder) confirming successfully submitted information.

– If the information submitted is not correct, missing, files in wrong format or too big, you will be asked to review the data/files and submit again.

! Please check the data and files submitted, if everything seems correct, press the green “SEND” button below.

? If you are having issues submitting files, you can just submit other information and ask for help on sending files from our representative who is handling your case.