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What is Embolization?
Dr. Aaron Kovaleski, MD
Kendra Payne, FNP-BC
Kyle Odvody, MS, FNP-BC
Greg Charleston, AGACNP-BC
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PREE Form
Patient-Rated Elbow Evaluation (PREE)
First Name
(Required)
Last Name
(Required)
Patient Date of Birth
(Required)
MM slash DD slash YYYY
Email
Today's Date
MM slash DD slash YYYY
Instructions: Please answer every question by circling the response that best describes your experience in the last week. If you are unsure, just give the answer that seems closest.
0 = No Pain, 10 = Worst Possible Pain
Pain (Past Week)
0 = No Pain, 10 = Worst Possible Pain
1. At rest
(Required)
0
1
2
3
4
5
6
7
8
9
10
2. With repeated wrist/hand movement
(Required)
0
1
2
3
4
5
6
7
8
9
10
3. Lifting a heavy object
(Required)
0
1
2
3
4
5
6
7
8
9
10
.4 At its worst
(Required)
0
1
2
3
4
5
6
7
8
9
10
5. Frequency of pain
(Required)
0
1
2
3
4
5
6
7
8
9
10
Function – Specific Activities
0 = Not Difficulty, 10 = Unable
6. Comb my hair
(Required)
0
1
2
3
4
5
6
7
8
9
10
7. Eat with a fork or spoon
(Required)
0
1
2
3
4
5
6
7
8
9
10
8. Pull a heavy object
(Required)
0
1
2
3
4
5
6
7
8
9
10
9. Use arm to rise from a chair
(Required)
0
1
2
3
4
5
6
7
8
9
10
10. Carry 10 lb. object at side
(Required)
0
1
2
3
4
5
6
7
8
9
10
11. Throw a small object (e.g., tennis ball)
(Required)
0
1
2
3
4
5
6
7
8
9
10
12. Use a telephone
(Required)
0
1
2
3
4
5
6
7
8
9
10
13. Do up shirt buttons
(Required)
0
1
2
3
4
5
6
7
8
9
10
14. Wash opposite armpit
(Required)
0
1
2
3
4
5
6
7
8
9
10
15. Tie my shoe
(Required)
0
1
2
3
4
5
6
7
8
9
10
16. Turn a doorknob
(Required)
0
1
2
3
4
5
6
7
8
9
10
Function - Usual Activities
0 = Not Difficulty, 10 = Unable
17. Personal care (dressing, washing)
(Required)
0
1
2
3
4
5
6
7
8
9
10
18. Household work (cleaning, maintenance)
(Required)
0
1
2
3
4
5
6
7
8
9
10
19. Work (job or daily work)
(Required)
0
1
2
3
4
5
6
7
8
9
10
20. Recreational activities
(Required)
0
1
2
3
4
5
6
7
8
9
10
