The Arm Clinic
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Shoulder Assessment Form

This questionnaire asks about your shoulder pain and its impact on your lifestyle. We use this as a tool to achieve a better understanding of how your shoulder is affecting you and ultimately improves the service that we offer you.

Step 1 of 10

10%
PLEASE TICK THE MOST APPROPRIATE RESPONSE FOR YOUR AFFECTED SHOULDER THROUGHOUT THIS QUESTIONNAIRE
DD slash MM slash YYYY
Affected Side(Required)
Dominant Arm(Required)

Pain

How would you describe the pain you usually get from your shoulder?(Required)
How would you describe the worst pain from your shoulder?(Required)
How would you describe tingling in your arm, shoulder or hand?(Required)
How much difficulty have you had sleeping due to your shoulder?(Required)

Function

How much difficulty have you had carrying shopping bags due to your shoulder?(Required)
How much difficulty have you had dressing yourself due to your shoulder(Required)
Can you hang clothes in a wardrobe with your affected arm?(Required)
Can you use a knife and fork at the same time?(Required)

Activities

How has your shoulder interfered with normal occupational activities?(Required)
How has your shoulder interfered with normal social activities?(Required)
How has your shoulder limited your leisure and recreational activities?(Required)
Have you found difficulty in playing sport / instrument due to pain in your shoulder, arm or hand?(Required)

Shoulder instability & dislocations

Do you have Dislocations or Instability?(Required)

Dislocations & Instability

Have you had shoulder dislocations or instability?(Required)
During the last six months, how many times has your shoulder slipped out of joint?(Required)
Have you avoided activity in case your shoulder slipped out of joint?(Required)
How much has your shoulder interfered with your ability to lift heavy objects?(Required)
How often has your shoulder been “on your mind”?(Required)

Abduction

Look at the illustrations below and try to carry out the movements one by one.
Abduction(Required)

Forward Flexion

Look at the illustrations below and try to carry out the movements one by one.
Forward Flexion(Required)

External Rotation

Look at the illustrations below and try to carry out the movements one by one.
External Rotation(Required)

Internal Rotation

Look at the illustrations below and try to carry out the movements one by one.
Internal Rotation(Required)

Strength of Abduction (lb)

(To 90 degrees abduction or highest level patient can achieve)
Strength of Abduction(Required)

Scores

Shoulder Assessment Form

This questionnaire asks about your shoulder pain and its impact on your lifestyle. We use this as a tool to achieve a better understanding of how your shoulder is affecting you and ultimately improves the service that we offer you.

Step 1 of 10

10%
PLEASE TICK THE MOST APPROPRIATE RESPONSE FOR YOUR AFFECTED SHOULDER THROUGHOUT THIS QUESTIONNAIRE
DD slash MM slash YYYY
Affected Side(Required)
Dominant Arm(Required)

Pain

How would you describe the pain you usually get from your shoulder?(Required)
How would you describe the worst pain from your shoulder?(Required)
How would you describe tingling in your arm, shoulder or hand?(Required)
How much difficulty have you had sleeping due to your shoulder?(Required)

Function

How much difficulty have you had carrying shopping bags due to your shoulder?(Required)
How much difficulty have you had dressing yourself due to your shoulder(Required)
Can you hang clothes in a wardrobe with your affected arm?(Required)
Can you use a knife and fork at the same time?(Required)

Activities

How has your shoulder interfered with normal occupational activities?(Required)
How has your shoulder interfered with normal social activities?(Required)
How has your shoulder limited your leisure and recreational activities?(Required)
Have you found difficulty in playing sport / instrument due to pain in your shoulder, arm or hand?(Required)

Shoulder instability & dislocations

Do you have Dislocations or Instability?(Required)

Dislocations & Instability

Have you had shoulder dislocations or instability?(Required)
During the last six months, how many times has your shoulder slipped out of joint?(Required)
Have you avoided activity in case your shoulder slipped out of joint?(Required)
How much has your shoulder interfered with your ability to lift heavy objects?(Required)
How often has your shoulder been “on your mind”?(Required)

Abduction

Look at the illustrations below and try to carry out the movements one by one.
Abduction(Required)

Forward Flexion

Look at the illustrations below and try to carry out the movements one by one.
Forward Flexion(Required)

External Rotation

Look at the illustrations below and try to carry out the movements one by one.
External Rotation(Required)

Internal Rotation

Look at the illustrations below and try to carry out the movements one by one.
Internal Rotation(Required)

Strength of Abduction (lb)

(To 90 degrees abduction or highest level patient can achieve)
Strength of Abduction(Required)

Scores

The Wilmslow Hospital,
52 Alderley Rd,
Wilmslow,
Cheshire,
SK9 1NY

Phone: 01625 545071/2/3

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