Name *

First Name

Last Name

Which shoulder is the problem? *

Right

Left

1. How would you describe the worst pain you had from your shoulder? *

None

Mild

Moderate

Severe

Unbearable

2. Have you had any trouble dressing yourself because of your shoulder? *

No trouble at all

A little bit of trouble

Moderate trouble

Extreme difficulty

Impossible to do

3. Have you had any trouble getting in and out of a car or using public transport because of your shoulder? *

No trouble at all

A little bit of trouble

Moderate trouble

Extreme difficulty

Impossible to do

4. Have you been able to use a knife and fork – at the same time? *

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

5. Could you do the household shopping on your own? *

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

6. Could you carry a tray containing a plate of food across a room? *

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

7. Could you brush/comb your hair with the affected arm? *

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

8. How would you describe the pain you usually had from your shoulder? *

None

Very mild

Mild

Moderate

Severe

9. Could you hang your clothes up in a wardrobe, – using the affected arm? *

Yes, easily

With little difficulty

With moderate difficulty

With great difficulty

No, impossible

10. Have you been able to wash and dry yourself under both arms? *

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

11. How much has pain from your shoulder interfered with your usual work (including housework)? *

Not at all

A little bit

Moderately

Greatly

Totally

12. Have you been troubled by pain from your shoulder in bed at night? *

No nights

Only 1 or 2 nights

Some nights

Most nights

Every night

Name *

First Name

Last Name

Which shoulder is the problem? *

Right

Left

1. How many times has your shoulder slipped out of joint (or dislocated)? *

Not at all in 6 months

1 or 2 times in 6 months

1 or 2 times per month

1 or 2 times per week

More often than 1 or 2 times/week

2. Have you had any trouble (or worry) with putting on a T-shirt or pullover because of your shoulder? *

No trouble/No worries

Slight trouble or worry

Moderate trouble or worry

Extreme difficulty

Impossible to do

3. How would you describe the WORST pain you have had from your shoulder? *

None

Mild ache

Moderate

Severe

Unbearable

4. How much has the problem with your shoulder interfered with your usual work? (Including school or college work, or housework) *

Not at all

A little bit

Moderately

Greatly

Totally

5. Have you avoided any activities due to worry about your shoulder - feared that it might slip out of joint? *

No, not at all

Very occasionally

Some days

Most days or more than one activity

Every day or many activities

6. Has the problem with your shoulder prevented you from doing things that are important to you? *

No, not at all

Very occasionally

Some days

Most days or more than one activity

Every day or many activities

7. How much has the problem with your shoulder interfered with your social life? (including sexual activity - if applicable) *

Not at all

Occasionally

Some days

Most days

Every day

8. How much has the problem with your shoulder interfered with your sporting activities or hobbies? *

Not at all

A little / occasionally

Some of the time

Most of the time

All of the time

9. How often has your shoulder been 'on your mind' - how often have you thought about it? *

Never, or only if someone asks

Occasionally

Some days

Most days

Every day

10. How much has the problem with your shoulder interfered with your ability - or willingness - to lift heavy objects? *

Not at all

Occasionally

Some days

Most days

Every day

11. How would you describe the pain you usually had from your shoulder? *

None

Very mild

Mild

Moderate

Severe

12. Have you avoided lying in certain positions, in bed at night, because of your shoulder? *

No nights

Only 1 or 2 nights

Some nights

Most nights

Every night