(858) 488-3597 info@waterandsportspt.com
CLICK HERE for our COVID protocols   Request An Appointment  CALL NOW: (858) 488-3597     FAX: (858) 724-1747

Upper Extremity

The safety of our employees and their family, our patients, are paramount above all else. As we learn more about the novel coronavirus and the disease it cases (COVID-19), we all have to do our part to limit its spread. We reply on guidance from the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and local health officials to guide our health and safety precautions as we continue to operate as an essential business that’s part of the nation’s critical infrastructure. 

 
To that aim, Water & Sports Physical Therapy has implemented enhanced screening of all employees and patients who come to a WSPT clinic. Your honest participation in this process is critical to maintaining everyone’s well being during this time.
Please answer the questions listed before coming in for your appointment.

"*" indicates required fields

QuickDASH

Please rate your ability to do the following activities in the last week by checking the number below the appropriate response.

Open a tight or new jar
Do heavy household chores (e.g., wash walls, floors)
Carry a shopping bag or briefcase
Wash your back
Use a knife to cut food
Recreational activities in which you take some force or impact through your arms, shoulders or hand (e.g., golf, hammering, tennis, etc.)
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 problems?

Please rate the severity of the following symptoms in the last week.

Arm, shoulder or hand pain
Tingling (pins and needles) in your arms, shoulder or hand
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?

WORK MODULE (OPTIONAL)

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking if that is your main work role).
If you check this box you may skip this section

Please circle the number that best describes your physical ability in the past week.

Using your usual technique for your work?
Doing your usual work because or arm, shoulder or hand pain?
Doing your work as well as you would like?
Spending your usual amount of time doing your work?

SPORTS/PERFORMING ARTS MODULE (OPTIONAL)

The following questions ask about the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which is most important to you.

If you check this box you may skip this section

Please circle the number that best describes your physical ability in the past week.

Using your usual technique for playing your instrument or sport?
Playing your musical instrument or sport because of arm, shoulder or hand pain?
Playing your musical instrument or sport as well as you would like?
Spending your usual amount of time practicing or playing your instrument or sport?
Patient Name*
MM slash DD slash YYYY