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Name (*):

First surname (*): Second surname:

Telephone(s) (*): Email (*):

Address (*):

City or town (*): Postal code (*):

ID (*): Birthdate
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Height (*): Weight (*):

: Occupation/job (*):
-- SELECT -- Right-handed Left-handed Ambidextrous

How you heard about us (*):

Where is your problem located? (please select)

Symptoms (please select)

Is the pain the result of a trauma, accident or other?
-- SELECT -- Yes No

If yes, please tell us the date and give a brief description of how it came about (sport, work, traffic accident, etc):

If it is a sports injury, please tell us which level (amateur, professional, etc):

How long have you had symptoms?

Diagnosis (if you know):

Do you take medication for pain?
-- SELECT -- Yes No

If yes, say which Aspirin, Paracetamol, Anti-inflammatory medication, etc:

How severe is the pain? On a scale of 0 (no pain) to 10 (very severe pain):

Does it hurt at night? Are you awoken by pain?
-- SELECT -- Yes No -- SELECT -- Yes No

You have pain in...? -- SELECT -- Groin Gluteus Low back Lateral thigh Other place

Observations:

In which situations does it hurt LESS? Mark them:

In which situations does it hurt MORE? Mark them:

In which part of the shoulder do you feel the pain? -- SELECT -- Front part In the shoulder Neck part Others (observations)

In which part of the elbow do you feel the pain? -- SELECT -- On the sides Front part On the back part Other place

Observations:

Where is your wrist\'s/hand\'s pain?: -- SELECT -- Wrist Fingers Thumb base Other place

Observations:

Do you feel strength-loss? -- SELECT -- Yes No

Is your mobility limited -- SELECT -- Yes No

Do you feel prickling (Shoulder)? -- SELECT --

Do you feel sensibility-loss (Shoulder)? -- SELECT --

Do you feel prickling (Elbow)? -- SELECT --

Do you feel sensibility-loss (Elbow)? -- SELECT --

Do you feel prickling (Wrist-Hand)? -- SELECT --

Do you feel sensibility-loss (Wrist-Hand)? -- SELECT --

Do you feel joint blocking? -- SELECT -- Yes No

Describe your current limitations:

Do you have any imaging tests? Please select and provide the date(s):

Have you been diagnosed with arthrosis before?
-- SELECT -- Yes No

If yes, please say which joint and provide the date of diagnosis:

Have you ever had the joint injected with hyaluronic acid, cortico-steroids and/or PRGF? :
-- SELECT -- Yes No

If yes, say which, in which joint and the date:

Do you take medication for pain?
-- SELECT -- Yes No

If yes, say which Aspirin, Paracetamol, Anti-inflammatory medication, etc:

Do you take any medicine specifically for arthrosis?
-- SELECT -- Yes No

If yes, say which:

Are you allergic to any medicine? -- SELECT -- Yes No

If so, please say which medicine

Do you have any hereditary illness? -- SELECT -- Yes No

If so, please say which:

Do you have (or have you had) any heart problems?
-- SELECT -- Yes No

Do you have gastritis / a gastric ulcer? -- SELECT -- Yes No

Are you diabetic? -- SELECT -- Yes No

Do you have liver problems / hepatitis? -- SELECT -- Yes No

Do you have any kidney disease? -- SELECT -- Yes No

Do you have problems of blood-clotting? -- SELECT -- Yes No

Are you a smoker? Do you consume alcoholic drinks?
-- SELECT -- Regular smoker Occasional smoker Ex-smoker Non smoker -- SELECT -- Every day Occasionally Weekends Never

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