Describe the type of pain and frequency of the pain e.g Constant dull ache, intermittent sharp pain
About your pain
Do you ever hear a crack or popping noise, or feel a clunking sensation?
no Where you able to continue with the activity or sport or did you have to stop yes able to continue no had to stop First Name Last Name Email address Postcode Tel Number Age Elbow How long have you had this problem ? Please describe the type of pain and frequency of the pain, e.g Constant dull ache, intermittent sharp pain Does moving your neck hurt Do you feel pain on gripping Do you have any numbness or pins and needles in the arm or hand What caused the injury e.g no real cause just came on gradually injury at work playing sport fall car accident Is there any bruising or swelling yes no Have you got full normal range of movement yes no Where you able to continue with the activity or sport or did you have to stop yes able to continue no had to stop First Name Last Name Email address Postcode Tel Number Wrist or Hand How long have you had this problem ? Please describe the type of pain and frequency of the pain, e.g Constant dull ache, intermittent sharp pain Do you have any tingling or numbness in the hand or fingers What caused the injury e.g no real cause just came on gradual, injury at work playing sport fall car accident Is there any bruising or swelling yes no Have you got full normal range of movement yes no Where you able to continue with the activity or sport or did you have to stop yes able to continue no had to stop First Name Last Name Email address Postcode Tel Number Hip/Thigh How long have you had this problem ? Where exactly is this pain? Do you ever hear a crack or popping noise, or feel a clunking or snapping sensation? Please describe the type of pain and frequency of the pain, e.g Constant dull ache, intermittent sharp pain Do you have any lower back pain Do you have any referred pain down the leg into the thigh, lower leg or foot? What caused the injury e.g no real cause just came on gradual, injury at work playing sport fall car accident Is there any bruising or swelling yes no Have you got full normal range of movement yes no Where you able to continue with the activity or sport or did you have to stop yes able to continue no had to stop First Name Last Name Email address Postcode Tel Number Knee How long have you had this problem ? Do you ever hear a crack or popping noise, or feel a clunking sensation? Please describe the type of pain and frequency of the pain, e.g Constant dull ache, intermittent sharp pain Does impact increase the pain, walking, running, jumping etc Does the knee give way Does the knee lock Which hurts more ascending stairs, descending stairs up down both neither What caused the injury e.g no real cause just came on gradual, injury at work playing sport fall car accident Is there any bruising or swelling yes no Have you got full normal range of movement yes no Where you able to continue with the activity or sport or did you have to stop yes able to continue no had to stop First Name Last Name Email address Postcode Tel Number Calf How long have you had this problem ? Did you feel a crack or popping noise, or feel a snapping or tearing sensation Please describe the type of pain and frequency of the pain, e.g Constant dull ache, intermittent sharp pain What caused the injury e.g no real cause just came on gradual, injury at work playing sport fall car accident Is there any bruising or swelling yes no Have you got full normal range of movement yes no Were you able to continue with the activity or sport or did you have to stop yes able to continue no had to stop First Name Last Name Email address Postcode Tel Number Shin How long have you had this problem ? Please describe the type of pain and frequency of the pain, e.g Constant dull ache, intermittent sharp pain What caused the injury e.g no real cause just came on gradual, injury at work playing sport fall car accident Is there any bruising or swelling yes no Have you got full normal range of movement of the ankle yes no Where you able to continue with the activity or sport or did you have to stop yes able to continue no had to stop First Name Last Name Email address Postcode Tel Number Foot/ankle How long have you had this problem ? Do you ever hear a crack or popping noise, or feel a clunking sensation? Does your ankle ever give way or feel like it may give way on you.
What caused the injury e.g. no real cause just came on gradual, injury at work , playing sport, car accident etc
About your pain
Did the foot get twisted inwards or outwards at the time of the injury?
Can you put weight on the foot to walk?
Is there any bruising or swelling?
Have you got full normal range of movement?
Were you able to continue with the activity or sport or did you have to stop?
Your Details
First Name
Last Name
Email Address
Contact Number
Post Code
Age
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