Pain and Activity
1. Please select your average level of daily pain
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
2. Please circle how you would rate your shoulder today as a percentage of normal
*
Please Select
0
10
20
30
40
50
60
70
80
90
100
3. Please select your current level of daily activity
*
Unaffected Sleep
Full Work
Full Recreation/Sport
Range of Motion
In order to assess how your shoulder is functioning we are going to ask you to complete a few simple movements and respond by circling yes or no with the corresponding movement. All of these movements should be completed with your affected shoulder. For the first section please stand or sit with your back and head against a wall.
4. Can you touch your chest?
*
Yes
No
5. Can you touch your chin?
*
Yes
No
6. Can you touch your nose?
*
Yes
No
7. Can you touch the top of your head?
*
Yes
No
8. Can you touch the back of your head?
*
Yes
No
9. Can you reach your opposite armpit?
*
Yes
No
10. Can you reach your back pocket on the same side?
*
Yes
No
11. Can you reach your lower back?
*
Yes
No
12. Stand with your affected shoulder against the wall facing right for right shoulder and left for the left shoulder. Hold your elbow at 90 degrees and try to touch the wall with the back of your hand. Can you touch the wall with the back of your hand?
*
Yes
No
Special Tests
For the next section we are going to ask you to complete a few tasks that will tell us what motions are painful for you. These movements will involve both arms.
13. Raise your hand as high as you can out to your side then lower your arm slowly. Is this painful when you lower the arm?
*
Yes
No
14. Place your hand across your body and pull it close to your body with your free hand. Is this painful?
*
Yes
No
15. Press on your belly. Is this painful?
*
Yes
No
16. Stand with your back to a wall and place the back of your hand on your lower back and then press backwards against the wall. Is this painful?
*
Yes
No
17. Hold your arm straight in front of you as if you were holding a platter and try not to let this hand move. Gently press down on your arm with your other hand. Is this painful?
*
Yes
No
For the next section we will ask you to perform a few movements whilst resisting them with your free hand. All of these should be performed with your arm (elbow) at your side, your elbow bent to 90 degrees and your thumb pointing up.
18. Place your hands together and press them together. Does your shoulder feel weak? Is this painful?
*
Weak
Painful
Both
Neither
19. Place your free hand on the back of your hand and then try to move your affected hand outward. Does your shoulder feel weak? Is this painful?
*
Weak
Painful
Both
Neither
20. Hook your free hand around your elbow and try to push your elbow away from your body. Does your shoulder feel weak? Is this painful?
*
Weak
Painful
Both
Neither
Thank you for filling out this assessment tool. Please check your answers above and when you're happy select 'submit' below to email this to your Physio
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