Revision Shoulder Replacement Questionnaire

If you have had bilateral surgery, please use one form for the left shoulder and one form for the right shoulder.

If there are reasons other than the operation which would stop you doing one of the tasks listed; try to answer the question from the joint replacement aspect alone.

Patient Name *

Joint Registry Reference (if known)

Date of Birth

Day

Month

Year

Patient Address

Operating Surgeon

Date of Surgery

Day

Month

Year

Dominant Arm *

Left

Right

Side *

Left

Right

Question 1 - How would you describe the worst pain you have had from your operated on shoulder? *

Question 2 - How would you describe the pain you usually have from your operated on shoulder? *

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

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

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

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

Question 7 - Could you brush/comb your hair with the operated on arm? *

Question 8 - Have you had any trouble dressing yourself because of your operated on shoulder? *

Question 9 - Could you hang your clothes up in a wardrobe - using the operated on arm? *

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

Question 11 - How much has pain from your operated on shoulder interfered with your usual work hobbies or recreational activities (including housework)? *

Question 12 - Have you been troubled by pain from your operated on shoulder in bed at night? *

Progress Report

I wish to receive a progress report on the study.

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