Sports Medicine Orthopedic Surgeon – Houston, TX Dr. David Lintner, M.D.

Timmons Office: (713) 441-3560 (map)
Baytown Office: (832) 556-0880 (map)

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Shoulder Injury Questionnaire for New Patients

Download the Questionnaire for New Patients with Shoulder Injuries in PDF format.

Please complete this form BEFORE your appointment.

Name*
PrefixFirstLastSuffix
Age*
Height*
Weight*
Email Address*
Best Daytime Phone*
Who is your primary care physician?
When did you last see him/her?
Have you ever had any of the following (in the past)?
- Asthma
- Balance Problems
- Bladder or Urinary Infections
- Blood in Stools
- Blood Clots
- Cancer
- Chest Pain
- Chronic Bronchitis
- Cramping in Leg While Walking
- Colitis
- Deep Venous Thrombosis
- Diabetes
- Dizziness
- Emphysema
- Fainting
- Frequent Bloody Noses or Bleeding Gums
- Gallstones
- Heart Attack
- Heart Murmur
- Heart Surgery
- High Blood Pressure
- High Cholesterol
- Joint Replacement
- Kidney Stones
- Osteoporosis
- Poor Circulation
- Recurrent Infections
- Shortness of Breath
- Slowly Healing Wounds
- Stomach Ulcer
- NORMAL. I've had none of the above.
Type of Cancer?
Review of Systems...
Do you currently have any of the following?
- Reaction of NSAID/anti-inflammatory medications (Advil, Ibuprofen, Naproxen, Indocin, Celebrex, etc.)
- Fever or chills.
- Recent weight gain or recent weight loss.
- Changes in vision, sensitivity to light, blurred vision, double vision.
- Change in hearing, bloody noses, sore throat, cough.
- Shortness of breath, chest pain, wheezing, coughing of blood.
- Palpitations, light headedness, dizziness.
- Loss of appetite, weight loss, pain with swallowing, nausea, vomiting, abdominal pain or bloating, blood in your stools, diarrhea, constipation.
- Difficulty urinating, pain with urination, blood in your urine.
- Rashes, insect bites, new skin lesions.
- NORMAL. I've had none of the above.
What medications do you take?
Are you allergic to any medications?
- Yes
- No
To which medications are you allergic?
Do you smoke?
- Yes
- No
How many packs per day?
How much alcohol do you drink?
What surgeries have you had in the past?
Shoulder History...
To which shoulder does the following apply?
- Right
- Left
When did your shoulder problem begin?
How did it start?
- Sports Injury
- Work Injury
- Overuse (Running, cycling, swimming, etc.)
- Work Overuse
- Gradually
- Spontaneously (For no apparent reason.)
What treatment have you had for this shoulder injury?
- Medications
- Physical Therapy
- Cortisone Injection
- Surgery
Have you had any of the following for this shoulder injury?
- X-Ray
- MRI
- CT Scan
If so, please bring the films to the office with you!
Have you had this problem before?
- Yes
- No
What part of your shoulder hurts?
- Front
- Outer Side (Deltoid Region)
- Back
- Upper
- Shoulder Blade
- Base of Neck / Trapezius Region
What makes the pain worse?
- Prolonged use.
- Reaching or using over head.
- Throwing or hitting a tennis serve.
- Lifting weights.
- Pulling an object off a shelf (Ex: gallon of milk out of refrigerator)
- Pulling an object up from the floor (suitcase, etc.)
- Tucking in a shirt.
Which exercises?
Does the pain wake you up from sleep?
- Yes
- No
Is the pain worse when you throw or serve, and which part of the throw hurts the most?
- Cocking
- Ball Release (or striking the tennis ball)
- Finishing the throw (follow-through)
Do you have any of the following?
- Painful popping.
- Sensation of catching. (Something getting caught/pinched between the bones.)
- Coming out of joint.
- Dead Arm
- Pain radiating down arm.
- Numbness in arm.
- Swelling or discoloration of arm after throwing.
- None of the above.
To where does the pain seem to travel?
Has the shoulder ever come out of joint...
- Part way? (Subluxation, the bones feel like they slip out of place.)
- All the way? (Dislocation)
- None of the above.
Describe your job's physical demands...
- Manual Labor: including lifting, carrying, pulling, pushing, working with arms over head (eg, mechanic, construction, laborer, etc.)
- Moderate: regular use of arms but not heavy.
- Office Environment
- Student
- Athlete
- Other
Are you currently working at your usual job?
- Yes
- No, light duty.
- No, off work due to injury.
- No, off work for other reasons.
What were your typical most strenuous recreational activities before your knee problem began?
- High intensity sports (football, baseball, basketball, tennis, racquetball, etc.)
- Moderate intensity sports (recreational skiing, running, cycling, etc.)
- Low intensity sports (walking, golf, etc.)
- Activities of daily living.
What are your most strenuous activities since your knee problem began?
- High intensity sports (football, baseball, basketball, tennis, racquetball, etc.)
- Moderate intensity sports (recreational skiing, running, cycling, etc.)
- Low intensity sports (walking, golf, etc.)
- Activities of daily living.
To what type of activities do you intend to return after your knee problem resolves?
- High intensity sports (football, baseball, basketball, tennis, racquetball, etc.)
- Moderate intensity sports (recreational skiing, running, cycling, etc.)
- Low intensity sports (walking, golf, etc.)
- Manual Labor
- Desk Job
- Activities of daily living.
Do you lift weights for exercise/recreation? If so, how many times per week?
- Less than two times per week.
- Two to three times per week.
- More than three times per week.
- Bodybuilder
- Don't lift weights.
Have you had an MRI?
- Yes
- No
What did the MRI show?
What prior injuries have you had to this shoulder?
- NONE
- Cartilage or Labral Tear
- Dislocation
- Subluxation
- Sprain or Strain
- Rotator Cuff Tear (Partial)
- Rotator Cuff Tear (Complete)
- Separation
- Impingement
What surgeries have you had on this shoulder?
- None
- Arthroscopy
- Labral Repair
- Tightening of Shoulder (Open)
- Tightening of Shoulder (Arthroscopic)
- Bankart Repair/Reconstruction (Open)
- Bankart Repair/Reconstruction (Arthroscopic)
- Debridement / Cleaning Out
- Rotator Cuff Repair (Open)
- Rotator Cuff Repair (Arthroscopic)
- Removal of Outer Portion of Clavicle
Year of your Arthroscopy?
Please enter a value between 1950 and 2020.
Year of your Labral Repair?
Year of your Tightening of Shoulder?
Year of your Bankart Repair or Reconstruction?
Year of your Debridement?
Year of your Rotator Cuff Repair?
What are your goals for this visit?
- Gain information about condition.
- make sure you are not damaging shoulder.
- Correct the problem as long as it does not involve surgery.
- Correct the problem even if it requires surgery.
Year of the removal of the outer portion of your clavicle?
eSignature
- I certify that I am the patient named above, and that all the responses contained in this form are accurate to the best of my knowledge.
- I certify that I am the parent or legal guardian of the patient named above, and that all the responses contained in this form are accurate to the best of my knowledge.
Name of Parent or Legal Guardian
PrefixFirstLastSuffix
Email
This field is for validation purposes and should be left unchanged.

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Dr. David Lintner

Dr. David Lintner specializes in arthroscopic surgery of the knee and shoulder and is active in teaching orthopedic surgeons the latest techniques. He also specializes in injuries to throwers’ shoulders and elbows, having written more than thirty scientific articles about ACL injuries, thrower’s injuries, and other sports medicine issues.

Read more about Dr. David Lintner

Pages in this Site

Orthopedic Sports Medicine Specialist
Dr. David Lintner
Our Staff
Sports Injuries
Surgery Information
Rehab Protocols
Appointments
Articles
Contact

Most Recent Articles

Dr. Lintner interviewed about faking of injuries in the NFL.
US News and World Report names Dr. Lintner to “The Best Doctors in America”
Radio Interview
How Texas is Striving to Make Football Safer
A Little Preparation Can Make for Safer Skiing

Orthopedic Links

American Association of Orthopedic Surgeons
DS2 Rehab Systems (The DS2 Platform)
Journal of the American Academy of Orthopaedic Surgeons
The American Orthopaedic Society For Sports Medicine

Rehabilitation

DS2 Rehab Systems (The DS2 Platform)

Sports Links

DS2 Rehab Systems (The DS2 Platform)
TSU Tigers

Timmons Office: (713) 441-3560 (map)
Baytown Office: (832) 556-0880 (map)

©2003-2010 Dr. Lintner, MD. All Rights Reserved.

Dr. David Lintner is an orthopedic sports medicine specialist practicing in Houston, TX, as well as team doctor to many of the professional teams in the Houston area.

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