The Bodyworks Clinic Carretera de Cadiz N340, Km 165,5 Cancelada 29688 Estepona Málaga Tel: 952 883 151 Fax: 952 888 359 info@marbellaphysio.com
To help our efforts going forward and in order to correlate and give statistical meaning to the successes of our MRT treatments, kindly complete the following questionnaire.
While this may look long, it will only take a few minutes and will help us both see the benefits you have received from this treatment.
Many thanks for your time.
Estelle Mitchell Chartered Physiotherapist Member of Health Professions Council Member of Organisation of Chartered Physiotherapists in Private Practice Spanish Col No 2070
Patient Name
Contact email address
Please rate your pain since the MRT on a scale of 0 to 10 with 0 being no pain and 10 being insufferable pain in the following situations:
When the pain is at its worst:
How often has the pain been this bad since MRT?
How would you describe the pain since MRT?
What score would you give the pain when the joint is under stress, for example going upstairs or performing a certain action:
When you are at rest, either in bed or sitting comfortably:
Are you using any pain relief?
no yes - over the counter remedies yes - prescription
If yes how often do you require pain relief?
Does your pain affect your sport?
It does not affect it at all I can play but have pain afterwards I can play but with pain I need pain relief to play I need pain relief and play less often I am unable to play due to the pain even with pain relief
Which elbow was treated?
Left Right
Please rate how easy or difficult the following tasks are with 0 being no problem at all and 10 being impossible
Putting your wallet in your back pocket
Using your arm to stand up from a chair
Wiping yourself after going to the bathroom
Washing the opposite shoulder
Using a knife and fork
Combing your hair
Lifting a 5 – 7kg weight with the arm at the side (like a bicep curl)
Dressing yourself
Pulling the cork from a wine bottle
Drying yourself
Doing your job
Please let us know if there are any other tasks you find difficult or changes that we should be aware of:
Please rate how easy the following movements are using the same scoring system:
Bending your arm
Straightening your arm
Bend your arm 90º and roll your hand inwards so your palm faces the floor
Bend your arm 90º and roll your hand outwards so your palm faces the ceiling
Please let us know if there are any other movements that trouble you:
If you are happy, it would be great to receive any feedback you would like to provide on the service and on the treatment itself and if this is by way of a testimonial, hopefully you are OK for me to publish this, anonymously should you wish.
Of course if for any reason you are unhappy, please do let me know so that things can be changed going forward.
