Initial Shoulder Information Form

  • (Date: Please try to be as specific as possible.)
  • 0 being no pain and 10 being pain as bad as it can be
  • Select the number that indicates your ability to do the following activities:

    0 - Unable to do, 1 - Very difficult to do, 2 - Somewhat difficult to do, 3 - Not difficult to do
  • The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
  • During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
  • During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
  • These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling….. How much of the time during the past 4 weeks…