Elbow Evaluation Form

Intro

E. Edward Khalfayan, M.D.

drkhalfayan.com

Name

Date

Age

Was there an Injury?

Yes

Describe what happened to elbow? (i.e. fall, pop/pain when throwing a ball)

Please select any of the following. For multiple select, press CTRL+Click

Do you have:

How severe is pain? (None) 0 1 2 3 4 5 6 7 8 9 10 (Severe)

Is pain constant?

What makes pain worse?

What makes pain better?

Previous elbow injuries and dates

Previous treatment

Medications: (Select all that apply - CTRL+Click for multi-selection)

Injections:

Type of Injection: Cortisone, PRP, Other. Please list type and dates

Physical Therapy?

If you answered Yes to the question above, was it helpful or not? Please explain.

Any additional comments regarding mediation, injections, treatment or physical therapy.

Previous Elbow Surgery? If Yes, please provide Surgeon name and date of procedure

Have you had any of the following as a result of this condition? Please select all that apply by pressing CTRL+Click

If selected "Other Tests" above, please explain.

Sports/recreational activities

Level of sport currently (CTRL+Click for multi-select)

Occupation

Current School and Grade Level

Goals after treatment for this problem

For Baseball Players

Position

Do you play year round?

How many teams?

When is the last time you played?

Average pitch count

Please Select One:

Please Select One: Involved Elbow:

Please Select: Is either side worse:

When did problem start?

Which part of throwing cycle causes pain? (Select all that apply by pressing CTRL+Click)

Elbow Evaluation Form

Intro

Please select any of the following. For multiple select, press CTRL+Click

Previous treatment

For Baseball Players

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