How long have you had your symptoms? What caused your symptoms? Unknown Injury Other: □ □ □ What % of your symptoms are in the NECK and ARM? What % of your symptoms are in each ARM? (please (please check one box) check one box) Neck 0%, Arm 100% No ARM symptoms □ □ Neck 10%, Arm 90% Right 0%, Left 100% □ □ Neck 25%, Arm 75% Right 10%, Left 90% □ □ Neck 50%, Arm 50% Right 25%, Left 75% □ □ Neck 75%, Arm 25% Right 50%, Left 50% □ □ Neck 90%, Arm 10% Right 75%, Left 25% □ □ Neck 100%, Arm 0% Right 90%, Left 10% □ □ 100%, Left 0% □ Where in your ARM do you have Where in your ARM do you have Where in your ARM do you have PAIN or TINGLING? NUMBNESS? WEAKNESS? Left Right Left Right Left None None None None None None □ □ □ □ □ □ Upper Back Upper Back Upper arm Upper arm Shoulder Shoulder □ □ □ □ □ □ Shoulder Shoulder Forearm Forearm Arm Arm □ □ □ □ □ □ Upper arm Upper arm Thumb Thumb Forearm Forearm □ □ □ □ □ □ Forearm Forearm Index finger Index finger Hands Hands □ □ □ □ □ □ Hand Hand Ring/small Ring/small □ □ □ □ BACK PAIN LEG PAIN NECK PAIN ARM PAIN
How long have you had your symptoms? What caused your symptoms? □ Unknown □ Injury □ Other: What % of your symptoms are in the NECK and ARM? (please check one box) □ Neck 0%, Arm 100% □ Neck 10%, Arm 90% □ Neck 25%, Arm 75% □ Neck 50%, Arm 50% □ Neck 75%, Arm 25% □ Neck 90%, Arm 10% □ Neck 100%, Arm 0% What % of your symptoms are in each ARM? (please check one box) □ No ARM symptoms □ Right 0%, Left 100% □ Right 10%, Left 90% □ Right 25%, Left 75% □ Right 50%, Left 50% □ Right 75%, Left 25% □ Right 90%, Left 10% □ 100%, Left 0% Where in your ARM do you have PAIN or TINGLING? Left □ None □ None □ Upper Back □ Upper Back □ Shoulder □ Shoulder □ Upper arm □ Upper arm □ Forearm □ Forearm □ Hand □ Hand Where in your ARM do you have NUMBNESS? Right Left □ None □ None □ Upper arm □ Upper arm □ Forearm □ Forearm □ Thumb □ Thumb □ Index finger □ Index finger □ Ring/small □ Ring/small Where in your ARM do you have WEAKNESS? Right Left □ None □ None □ Shoulder □ Shoulder □ Arm □ Arm □ Forearm □ Forearm □ Hands □ Hands BACK PAIN LEG PAIN NECK PAIN ARM PAIN