SHOULDER



Part I: Pain Satisfaction: Please choose the number closest to your level of pain or satisfaction:

1. Pain at rest with your arm by your side:

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No Pain Worst Pain Possible


2. Pain with normal activities(eating, dressing, bathing):

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No Pain Worst Pain Possible


3. Pain with strenuous activities(reaching, lifting, pushing, pulling, throwing):

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No Pain Worst Pain Possible


4. How satisfied are you with the current level of function of your shoulder:

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Not Satisfied Very Satisfied



Part II: Function: Please choose the number that best describes the level of difficulty that you might have performing each activity:

.

  No Difficulty Some Difficulty Much Difficulty Can't do at all Did Not Do Before Injury
1. Reach the small of your back to tuck in your shirt with your hand 3 2 1 0 X
2. Wash the middle of your back/hook bra. 3 2 1 0 X
3. Perform necessary toileting activities. 3 2 1 0 X
4. Wash the back of opposite shoulder. 3 2 1 0 X
5. Comb hair. 3 2 1 0 X
6. Place hand behind head with elbow held straight out to the side. 3 2 1 0 X
7. Dress self(including put on coat and pull shirt off overhead). 3 2 1 0 X
8. Sleep on affected side. 3 2 1 0 X
9. Open a door with affected side. 3 2 1 0 X
10. Carry a bag of groceries with affected arm. 3 2 1 0 X
11. Carry a briefcase / small suitcase with affected arm. 3 2 1 0 X
12. Place a soup can(1-2lbs.) on a shelf at shoulder level wothout bending elbow. 3 2 1 0 X
13. Place a one gallon container(8-10lbs.) on a shelf at shoulder level without bending elbow. 3 2 1 0 X
14. Reach a shelf above your head without bending your elbow. 3 2 1 0 X
15. Place a soup can(1-2lbs.) on a shelf overhead without bending your elbow. 3 2 1 0 X
16. Place a one gallon container(8-10lbs.) on a shelf overhead without bending your elbow. 3 2 1 0 X
17. Perform usual sport / hobby. 3 2 1 0 X
18. Perform household chores (cleaning, laundry cooking). 3 2 1 0 X
19. Throw overhand / swim / overhead raquet sports. 3 2 1 0 X
20. Work full-time at your regular job. 3 2 1 0 X