Shoulder Survey 1 Year Post OP

1 Year from Surgery - Shoulder Survey

Dr. Shawn Hennigan
Patient Legal Name*

First NameLast Name
Birth Date*

MonthDayYear
Hello and Happy 1 year anniversary! We would appreciate a few minutes of your time to fill out the survey regarding how both shoulders feel and function. Thank you for allowing us the opportunity to take care of you! - Dr. Hennigan

0 = unable to do 1 = very difficult 2 = somewhat difficult 3 = not difficult

LEFT ARM*

	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*

	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.
Today's Date

MonthDayYear
Date
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