Patient Name *
Email
Joint Registry Reference (if known)
Operating Surgeon
Question 1 - How would you describe the worst pain you have had from your operated on shoulder? *
- Select - None Mild Moderate Severe Unbearable
Question 2 - How would you describe the pain you usually have from your operated on shoulder? *
- Select - None Very mild Mild Moderate Severe
Question 3 - Have you had any trouble getting in and out of a car or using public transport because of your operated on shoulder? *
- Select - No trouble at all A little bit of trouble Moderate trouble Extreme difficulty Impossible to do
Question 4 - Have you been able to use a knife and fork at the same time? *
- Select - Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible
Question 5 - Could you do the household shopping on your own? *
- Select - Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible
Question 6 - Could you carry a tray containing a plate of food across a room? *
- Select - Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible
Question 7 - Could you brush/comb your hair with the operated on arm? *
- Select - Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible
Question 8 - Have you had any trouble dressing yourself because of your operated on shoulder? *
- Select - No trouble at all A little bit of trouble Moderate trouble Extreme difficulty Impossible to do
Question 9 - Could you hang your clothes up in a wardrobe - using the operated on arm? *
- Select - Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible
Question 10 - Have you been able to wash and dry yourself under both arms? *
- Select - Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible
Question 11 - How much has pain from your operated on shoulder interfered with your usual work hobbies or recreational activities (including housework)? *
- Select - Not at all A little bit Moderately Greatly Totally
Question 12 - Have you been troubled by pain from your operated on shoulder in bed at night? *
- Select - No nights Only 1 or 2 nights Some nights Most nights Every night
Submit