Questionaire - Trigenics Valuravi ja Kiropraktika Kliinik

Personal Information

Your Full Name *

Sex *

Height *

cm

Weight *

kg

Date of Birth *

How did you first hear about us? *

Your Contact Details

Email *

Phone *

Address *

ZIP / Postal Code *

Country *

Occupation *

Job Description

Medical Doctor

Name of your Medical Doctor *

Specialty

Contact Phone

Contact Email

Other doctors or therapists you have seen for this problem

Doctor / Therapist Name

Specialty

Phone

Email

Doctor / Therapist Name

Specialty

Phone

Email

Your Condition

Please answer the questions below so that we can better understand your condition and advise you on the best next 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 sleep? *

Does it interfere with work? *

Does it interfere with daily routine? *

Was it result of an accident? *

If it was result of an accident, describe the circumstances

Movability

Percentage of shoulder movability. Total: 0/100, numbers only.

Right Side

Forwards *

%

Backwards *

%

Sideways *

%

Left Side

Forwards *

%

Backwards *

%

Sideways *

%

Past Diagnosis

Fields marked with * are required.

Please write a brief history of the condition

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 the comment field.

High Blood Pressure / Hypertension *

Comment

Neck pain — where? *

Comment

Joint degeneration and/or Arthritis *

Comment

Haemophilia or other blood disease *

Comment

Diabetes *

Comment

Osteoporosis or Osteopenia *

Comment

Whiplash injury / cervical sprain *

Comment

Numbness in the hands or fingers *

Comment

Have any relatives ever suffered a stroke? *

Comment

Have you had cortisone shots? *

Comment

Medication / Allergies

Shoulder Pain and Disability Index (SPADI)

Please rate your pain and difficulty level for each activity.

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? *

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 / 4.5kg? *

Removing something from your back pocket? *

Documents

You can upload X-rays, MRI files, pictures, videos, or medical reports.

Make sure files have different names. Use low resolution/quality settings for videos and photos.

1) X-Rays

Accepted file formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mpg, jpg, jpeg, png. Size limit per file is 4MB.

Right Shoulder — File 1

Right Shoulder — File 2

Left Shoulder — File 1

Left Shoulder — File 2

Neck — File 1

Neck — File 2

2) Medical Reports & MRI

Medical Report — File 1

Medical Report — File 2

MRI

3) Movement videos & photos

Accepted formats: pdf, rtf, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif, mov, wmv, rm. One file up to 10MB per field.

Please check your information before submitting. If you are having issues with files, submit the form and ask our representative for help.

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Personal Information

Your Contact Details

Medical Doctor

Other doctors or therapists you have seen for this problem

Your Condition

Date of Onset

Current Situation

Movability

Right Side

Left Side

Past Diagnosis

Shoulder Pain and Disability Index (SPADI)

Pain Scale — How severe is your pain?

Disability Scale

Documents

1) X-Rays

2) Medical Reports & MRI

3) Movement videos & photos

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