Texas Elbow Tendinopathy

Elbow Tendinopathy Questionnaire
First Name **
Last Name **
Email **
Phone Number *
Preferred Location **
Date of Birth **

MonthDayYear
How did you hear about us? **
Screening Questionnaire
Where is your pain?*

Outer ElbowInner ElbowBoth SidesNeither
How long have you had pain for?*

Less than one month1-3 months3-6 monthsLonger than 6 month
How did the pain start?*

GradualSudden
Does gripping or squeezing objects cause pain?*

AlwaysSometimesNever
Does lifting objects make your pain worse?*

With palm up?With palm down?Both palm up and downNeither
Does twisting your forearm cause pain (like turning a screwdriver or door knob)?*

YesNo
Does moving your wrist up and down cause pain?*

Bending wrist up (extension)?Bending wrist down (flexion)?Neither
Worst pain Severity within the last week on scale of 0-10?*

Mild (0-3)Moderate (4-6)Severe (7-10)
When do you notice more pain?*

During activityMostly at restDuring rest and activity
Does your elbow pain limit your ability to perform work, household, or recreational activities (including sports)?*

Not at allA little (mild)ModeratelyA lot (severe)
Is the pain in your dominant arm/hand?*

YesNo
Have you had prior diagnosis and treatment for elbow pain?*

YesNo
What treatments have you had for elbow pain (choose as many as needed)?

NoneRest from activityMedications such as Tylenol, Advil, Aleve, or otherStretching/rehab exercisesBraces or support garmentsHeat or ice therapyInjections such as steroid shots, PRP, stem cells or othersSurgeryOther
LIINE LOCATION
Have you scheduled an appointment with us before? **
LIINE IS NEW
Phone Condition
Total Score
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