Musculoskeletal Condition Form

Musculoskeletal Condition Form

Please answer the following questions as accurately as possible. Thank you!
Name:*

First NameLast Name
Age:*
Occupation:*
Hobbies:*
Answer all the regions you have trouble with:

(In the regions that "are not affected" please select that option)

Which side of your NECK is affected?*
When did this problem start? *
How did this neck problem happen?*
SIGNS AND SYMPTOMS

Is the pain / discomfort constant or intermittent?*
Others:
e.g. clicking
MOVEMENT
Can you bend your neck forward and look down without producing symptoms?*

YesNo
Can you extend your neck and look up without producing symptoms?*

YesNo
Can you bend your neck to the LEFT without producing symptoms?*

YesNo
Can you bend your neck to the RIGHT without producing symptoms?*

YesNo
Can you rotate your head to the LEFT without producing symptoms?*

YesNo
Can you rotate your head to the RIGHT without producing symptoms?*

YesNo
What movements/activities INCREASE the signs and symptoms?*
e.g. lying down on one side
What movements/activities INCREASE the signs and symptoms?*
e.g. lying flat supine
If you have consulted a medical professional, please specify your diagnosis:
Please upload your medical results, if you have any:

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Which SHOULDER is affected?*
When did this problem start? *
How did this shoulder problem happen?*
SIGNS AND SYMPTOMS

Is the pain / discomfort constant or intermittent?*
Others:
e.g. clicking, popping
MOVEMENT
Can you lift your arm/s overhead?*
Can you reach the opposite shoulder without pain/discomfort/difficulty?*
What movements/activities INCREASE the signs & symptoms?*
e.g. brushing hair, donning on or off clothes
What movements/activities DECREASE the signs & symptoms?*
e.g. supporting your arm, lying down
If you have consulted a medical professional, please specify your diagnosis:
Please upload your medical results, if you have any:

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Which ELBOW is affected?*
When did this problem start?*
How did this elbow problem happen?*
SIGNS AND SYMPTOMS

Is the pain / discomfort constant or intermittent?*
Others:
e.g. twisting, popping
MOVEMENT
Can you bend your elbow/s fully without pain/discomfort/difficulty?*

YesNo
Can you straighten your elbow/s fully without pain/discomfort/difficulty?*

YesNo
With elbows straight, can you flex your wrist without pain?*

YesNo
With elbows straight, can you extend your wrist without pain?*

YesNo
What movements/activities INCREASE the signs & symptoms?*
e.g. forceful gripping, holding a glass
What movements/activities DECREASE the signs & symptoms?*
e.g. supporting your elbow
If you have consulted a medical professional, please specify your diagnosis:
Please upload your medical results, if you have any:

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Which FOREARM / WRIST / HAND is affected?*
If fingers, please specify:*
e.g. right pointer finger
When did this problem start?*
How did this forearm/wrist/hand problem happen?*
SIGNS AND SYMPTOMS

Is the pain / discomfort constant or intermittent?*
Others:
e.g. twisting, clicking
MOVEMENT
Can you make a fist without pain/discomfort/difficulty?*

YesNo
Can you spread your fingers out without pain/discomfort/difficulty?*

YesNo
Can you flex your wrist without pain/discomfort/difficulty?*

YesNo
Can you extend your wrist without pain/discomfort/difficulty?*

YesNo
What movements/activities INCREASE the signs & symptoms?*
e.g. opening a jar, closing a bottle cap
What movements/activities DECREASE the signs & symptoms?*
e.g. supporting your hand or wrist
If you have consulted a medical professional, please specify your diagnosis:
Please upload your medical results, if you have any:

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Which part of your BACK is affected? Tick all that apply.

	Left Side	Center	Right Side	Both Sides
Upper Back
Mid Back
Lower Back

When did this problem start?*
How did this back problem happen?*
SIGNS AND SYMPTOMS

Please tick all that apply:

Is the pain / discomfort constant or intermittent?*

Do these symptoms wake you or keep you awake at night?*

Yes, alwaysYes, sometimesNo, not at all
Other signs & symptoms you may have:
e.g. snapping, clicking
MOVEMENT
Can you squat down without producing the familiar symptoms?*

YesNo
Can you bend your trunk forward without producing the familiar symptoms?*

YesNo
Can you bend your trunk on each side without producing the familiar symptoms?*

YesNo
Can you extend your trunk backwards without producing the familiar symptoms?*

YesNo
What movements/activities INCREASE the signs & symptoms?*
e.g. laughing, sneezing, straining, walking too long, sitting too long
What movements/activities DECREASE the signs & symptoms?*
e.g. lying down, sitting down
If you have consulted a medical professional, please specify your diagnosis:
Please upload your medical results, if you have any:

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Which HIP is affected? *
When did this problem start?*
How did this hip problem happen?*
SIGNS AND SYMPTOMS

Is the pain / discomfort constant or intermittent?*
Others:
e.g. snapping, popping
MOVEMENT
Can you squat down without producing your symptoms? *
Can you stand on one leg (right leg) without producing your symptoms? *
Can you stand on one leg (left leg) without producing your symptoms? *
What movements/activities INCREASE the signs and symptoms?*
e.g. running, going up the stairs
What movements/activities DECREASE the signs and symptoms?*
e.g. lying down with legs straight, sitting down
If you have consulted a medical professional, please specify your diagnosis:
Please upload your medical results, if you have any:

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Which KNEE is affected? *
When did this problem start?*
How did this knee problem happen?*
SIGNS AND SYMPTOMS

Is the pain / discomfort constant or intermittent?*
Others:
e.g. snapping, popping
MOVEMENT
Can you squat down without difficulty or producing symptoms?*

YesNo
Can you bend your knee/s without difficulty or producing symptoms?*

YesNo
Can you straighten your knee/s without difficulty or producing symptoms?*

YesNo
What movements/activities INCREASE the signs and symptoms?*
e.g. running, going up the stairs
What movements/activities DECREASE the signs and symptoms?*
e.g. lying down with legs straight, sitting down
If you have consulted a medical professional, please specify your diagnosis:
Please upload your medical results, if you have any:

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Which part is affected? Tick all that apply.

	Left Side	Right Side	Both Sides
Lower Leg
Ankle
Foot
Toes

If toes, please specify: *
e.g. right little toe, toe not affected, etc.
When did this problem start?*
How did this leg/ankle/foot problem happen?*
SIGNS AND SYMPTOMS

Is the pain / discomfort constant or intermittent?*
Others:
e.g. crepitus
MOVEMENT
Can you go onto your tiptoes without difficulty or producing symptoms?*

YesNo
Can you stand on your heels without difficulty or producing symptoms?*

YesNo
Can you curl your toes without difficulty or producing symptoms?*

YesNo
Can you fan your toes out without difficulty or producing symptoms?*

YesNo
What movements/activities INCREASE the signs and symptoms?*
e.g. tiptoes, going up the stairs
What movements/activities DECREASE the signs and symptoms?*
e.g. not putting weight on foot, sitting down
If you have consulted a medical professional, please specify your diagnosis:
Please upload your medical results, if you have any:

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If you have concerns not listed above, please describe them here:
Please upload any medical results you have.

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You may also email them to info@tayloredtraining.com.au Cancelof
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Thank You!
Should be Empty:

	Left Side	Right Side	Both Sides
Pain or Discomfort
Swelling / Inflammation
Redness / Bruising
Numbness, tingling or radiating signs

	Front part	Side part	Back part	Top shoulder	Whole shoulder
Pain or Discomfort
Swelling / Inflammation
Redness / Bruising
Numbness, tingling or radiating signs

	Medial side, close to the body	Lateral side, away from the body	Back portion	Whole elbow
Pain or Discomfort
Swelling / Inflammation
Redness / Bruising
Numbness, tingling or radiating signs

	Left side	Right side	Both sides
Pain or Discomfort
Swelling / Inflammation
Redness / Bruising
Numbness, tingling or radiating signs

	Left side	Right side	Both sides
Pain or Discomfort
Swelling / Inflammation
Redness, bruising or discoloration
Numbness, tingling or radiating signs