Shoulder ASES
Date
*
Shoulder
*
Left
Right
Name
*
First Name
Last Name
Usual Work
*
Usual Leisure Sport/Activity
*
Do you have shoulder pain at night?
*
Yes
No
Do you take painkillers such as paracetamol (acetaminophen), diclofenac?
*
Yes
No
Do you take strong pain killers such as codeine, tramadol or morphine?
*
Yes
No
Intensity of pain?
*
Please Select
1
2
3
4
5
6
7
8
9
10
Is it difficult for you to put a coat on?
*
Unable to do
Very difficult to do
Somewhat difficult
Not difficult
Is it difficult for you to sleep on the affected side?
*
Unable to do
Very difficult to do
Somewhat difficult
Not difficult
Is it difficult for you to wash your back/do up a bra?
*
Unable to do
Very difficult to do
Somewhat difficult
Not difficult
Is it difficult for you to manage toileting?
*
Unable to do
Very difficult to do
Somewhat difficult
Not difficult
Is it difficult for you to comb your hair?
*
Unable to do
Very difficult to do
Somewhat difficult
Not difficult
Is it difficult for you to reach a high shelf?
*
Unable to do
Very difficult to do
Somewhat difficult
Not difficult
Is it difficult for you to lift 4.5kgs above your shoulder?
*
Unable to do
Very difficult to do
Somewhat difficult
Not difficult
Is it difficult for you to throw a ball overhand?
*
Unable to do
Very difficult to do
Somewhat difficult
Not difficult
Is it difficult for you to do you usual work?
*
Unable to do
Very difficult to do
Somewhat difficult
Not difficult
Is it difficult for you to do your usual sport/leisure activity?
*
Unable to do
Very difficult to do
Somewhat difficult
Not difficult
Submit
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