Diagnostic Tool | Young In Motion

Your symptoms

Now we know a bit more about your lifestyle and the impact of your soreness, please let us know more about your symptoms so we can understand your specific problem better

How much does this pain or injury impact on your life? (choose the highest item on the list that applies to you)

The pain is constant and unrelenting

Stops me from getting a full night’s sleep

Stops me from doing many or all of my necessary tasks or work

Forces me to avoid or modify the way I do certain tasks or sport-leisure activities

Annoying or very uncomfortable at times

Barely noticeable

Pain Scale - How strongly do you experience your symptoms at its worst?

Type of Symptom(s)

Pain

Soreness

Stiffness - Lack of Movement

Weakness

Tingling

Numbness

Lack of Co-ordination

Fatigue, Tired easily

Where do you feel the MOST pain or stiffness?

Neck, Neck and shoulder, or head

Upper limb only (shoulder, arm, elbow, forearm, wrist, hand

Upper back

Lower Back and/ or buttocks

Lower limb ie. Legs (thigh, groin, knees, shin, calf, ankle, foot)

Which of the following BEST describes the SPECIFIC location of your pain or stiffness

at a joint, where movement occurs

over muscle(s), or in between either end of bones

in long lines, along the line of my arm or leg, or across my chest/back

in patches, the size of a coin or larger

the area of pain is often moving around

all over my body – there is no part without pain

Other: (you may not get a clear answer if this option is selected)

Symptom History

Now it will be helpful to know a little bit more about how the symptoms developed so we suggest how urgently you may need to take action

How long have you had this pain and / or stiffness?

less than 3 days

3 days to 6 weeks

more than 6 weeks but less than 3 months

3 months or more

Is your symptom (s) a result of :

a recent injury from a specific accident or incident

a specific incident over 3 months ago

a prolonged activity or posture

a repetitive activity

no apparent reason

As part of your daily life, do you usually handle anything heavy?

Yes

Are you sitting for long periods?

Yes

Did you have swelling in the area within 24 hours of developing your symptoms?

Yes

How quickly did swelling occur?

obviously swollen (esp if compared with the other limb/side of body) in less than 6 hours

moderate swelling within 6-24 hours

mild swelling - need to look carefully at the sore area to notice it

Within 15 minutes of the initial pain/injury (and the shock of it), were you able to move quite well (ie walk/ use the arm/ sit and stand)

Yes

Your situation

Let's find out more about your situation so we can give you some helpful information to guide you in the right direction

Which of the following best describes you?

Full-Time work or commitments

Part-Time work or commitments

Flexible or no commitments in my usual week

Which of the following best describes your home situation?

I assist children /adults with basic tasks/ essential life skills each day eg. Feeding; dressing; transport

I have a minor role in assisting someone else with basic life skills on a daily basis

I do not need to assist anyone else with basic life skills on a daily basis

When it comes to pain, what is your single biggest challenge right now? (Optional)

(Optional) If we could help you overcome the problem you're facing from having these symptoms, what would your life be like?

Is there any additional information you may wish to explain or add?

First Name

What ways do you prefer to be contacted?

Phone/Mobile

Facebook Profile name

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