SHOULDER QUESTIONNAIRE

Name: *

Which shoulder? *

Right

Left

Bilateral

When did the problem occur? *

How did the problem occur? *

Are you currently working? *

Yes

Have you had any previous problems with your shoulder? *

Yes

If yes, when? *

Do you have pain everyday? *

Yes

Does your shoulder wake you up from sleep? *

Yes

Do you have pain pushing? *

Yes

Do you have pain pulling? *

Yes

Do you have pain with carrying? *

Yes

Do you have pain lifting? *

Yes

What makes your pain worse? *

What makes your pain better? *

Does your pain travel or radiate? *

Yes

Can you work with your arm at shoulder level? *

Yes

Can you work with your arm above shoulder level? *

Yes

How does your shoulder interfere with your work? *

Are there any other activities you are unable to do? (sports, housework, grooming, etc.) *

Have you had any surgery? *

Yes

If yes, when?

Have you had any MRI's? *

Yes