Disabilities of the Arm, Shoulder, & Hand Form:

Please fill out the new patient paperwork online and submit to our office prior to your first visit.

 

Due to COVID-19, we want to minimize patient time spent in the waiting area.  We pride ourselves on maximizing your time with your physical therapist to work one on one and begin the process of recovery.  Paperwork is an unfortunate necessity of the process but we want to minimize this burden and have it done prior to your visit so that we can get your treatment started!

FORM - DISABILITIES OF THE ARM, SHOULDER, & HAND

Open a tight or new jar

Write

Turn a key

Prepare a meal

Push open a heavy door

Place an object above your head

Do heavy household chores (e.g wash wall, wash floors, wash floors)

Garden or yard work

Make a bed

Carry a shopping bag or briefcase

Wash or blow dry your hair

Wash your back

Put a pullover sweater

Use a knife to cut food

Recreational activities which require little effort (e.g card playing, knitting, etc.)

Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g golf, hammering, tennis, etc.)

Recreational activities in which you move your arm freely (e.g playing frisbee, badminton, etc.)

Manage transportation needs (getting from one place to another)

Sexual activities

During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbors or groups?

During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem?

Arm, shoulder or hand pain level

Arm, shoulder or hand pain when you performed any specific activity

Tingling (pins & needles) in your arm, shoulder, or hand

Weakness in your arm, shoulder, or hand

Stiffness in your arm, shoulder, or hand

During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?

I feel less capable, less confident or less useful because of my arm. shoulder or hand problem.

14 + 12 =

Our front office person administrator will inform you of the proper functional outcome to fill out and submit as well.  Your therapist will score this and establish a baseline of how you currently rate your symptoms.

If you need to contact Dr. Damon Daura, the email is: Damon@DamonPT.com

For any questions – please reach out! 
Totowa 973-237-1975   |   Lafayette Township 973-862-6377