Shoulder Survey
Dr. Shawn Hennigan
Patient Legal Name
*
First Name
Last Name
Birth Date
*
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Please select a year
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Date of your upcoming appointment with Dr. Hennigan
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Month
-
Day
Year
Date
Please answer the questions below by clicking the number that applies to you. Please do this for both arms, regardless of pain or injury.
0 = unable to do 1 = very difficult 2 = somewhat difficult 3 = not difficult
LEFT ARM
*
Rows
0
1
2
3
Can you put on your coat unassisted?
Can you sleep on your shoulder comfortably?
Can you manage toileting unassisted?
Can you wash your back or fasten your bra (in back)?
Can you comb/wash your hair?
Can you reach a shelf over your head?
Can you lift 10 lbs over shoulder level?
Can you throw a ball overhand?
Can you perform regular job duties?
Can you participate in your usual sports?
RIGHT ARM
*
Rows
0
1
2
3
Can you put on your coat unassisted?
Can you sleep on your shoulder comfortably?
Can you manage toileting unassisted?
Can you wash your back or fasten your bra (in back)?
Can you comb/wash your hair?
Can you reach a shelf over your head?
Can you lift 10 lbs over shoulder level?
Can you throw a ball overhand?
Can you perform regular job duties?
Can you participate in your usual sports?
Total Left Arm:
Total Right Arm:
Using the picture above, use the slider to describe your average level of pain level.
*
If there is a range of pain with the picture above, please enter the range.
Did you have an injury?
*
Yes
No
Date of Injury or Onset of symptoms:
Are you Diabetic?
*
Yes
No
What is your last Hgb A1C value?
Do you Smoke?
*
Yes
No
Any imaging of the injured shoulder? (Xray, MRI, CT) When and Where?
*
If none apply, type NONE
Any prior treatments? Medications? (list). Injections (when?). Therapy (How long?)
*
If none apply, type NONE.
Have you ever had surgery on this shoulder?
*
Yes
No
Please describe date and surgery?
Today's Date
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Month
-
Day
Year
Date
MIPS is a program aimed to improve the quality of care provided to patients. Healthcare providers collect data on various areas to identify trends and areas where care can be improved. Please answer the following questions.
Fall History, choose one of the following
No Falls in the past year
One fall, without injury in the past year
One fall, with injury in the past year
Two or more falls with injury in the past year
Reach out to your PCP for fall prevention information or ask at your appointment for a referral.
Advanced Directive (AD)
Patient has an advance directive
Patient does not have an advanced directive
DNR
Durable power of attorney for Healthcare
Living Will
Submit
Should be Empty: