Shoulder Pain Questionnaire

1. Which shoulder hurts? L R Both (please circle one)

2. How long has your shoulder hurt? ________________________________

3. Did your shoulder pain begin as the result of a specific accident or injury? _________

If yes, please describe briefly: __________________________________________

_________________________________________________________________

_________________________________________________________________

4. Was the onset of your shoulder pain gradual? _____

5. Do you have shoulder pain at night which interferes with sleep? _______________

6. Have you been treated with any of the following for your shoulder pain:

_____Physical Therapy
_____Anti-inflammatory medication
_____Injections to the elbow
_____Steroid medications
_____Prior surgery

7. Do you have diabetes or thyroid disease? _________________________________

8. Is your pain increased with use of above shoulder height
(i.e. srewing in a light bulb? ___________________________________

9. Do you have increased pain reaching behind you (i.e. reaching for a billfold or
fastening a brassier)? ___________________________

10. Does your shoulder feel unstable? ______________________________

11. Have you ever dislocated your shoulder? ____________________

12. What is the name of your primary care physician? __________________________
    
    
    __________________________________________
    FOR PHYSICIAN USE ONLY
    AROM: FF_____ ABD_____ ER IN ADD_____ ER ABD_____

Impingement tests: 1 11 111 1V Crank speeds

Tenderness on Palpation: biceps_____ ant-lat acromion_____ coracoid_____ ACJ _____

Instability: sulcus_____ relocation_____ load ad shift_____

If localized, where_________________________

Visual inspection: symmetry_____ mass_____ scapulothoracic rhythm_____