435 King St. N, Waterloo

Shoulder and Elbow Disability Questionnaire

Please complete and submit this brief questionnaire PRIOR TO YOUR INITIAL CONSULTATION and PRIOR TO EACH FOLLOWUP VISIT with your orthopaedic surgeon or sports medicine physician.

The purpose of this questionnaire is to give your healthcare provider a better understanding of your pain and limitations so that we can be more informed to help you.  Completing this form in advance will help prevent the spread of COVID-19 by reducing your time spent in the waiting room and by limiting unnecessary handling of stationary materials at the office.



Shoulder and Elbow Disability Questionnaire

  • MM slash DD slash YYYY
  • Please rate your ability to perform the following activities in the past week:

  • Please rate the severity of the following symptoms in the last week: