First and Family Name
Date of Birth
Your Address
Your Email Address
Your Phone Number
Select (A)- Level of Pain (/15) Level of PainNo =15 ptsMild pain = 10 ptsModerate = 5 ptsSevere or permanent = 0
Select (B)- Activities of daily living (/20) Total (1 + 2 + 3 + 4) (B1)- Is your occupation or daily living limited by your shoulder? Is your occupation or daily living limited by your shoulder?No Limitation= 4 ptsModerate Limitation= 2 ptsSevere Limitation= 0
Select (B2)- Are your leisure and recreational activities limited by your shoulder? Are your leisure and recreational activities limited by your shoulder?No Limitation= 4 ptsModerate Limitation= 2 ptsSevere Limitation= 0
Select (B3)- Is your night sleep disturbed by your shoulder? Is your night sleep disturbed by your shoulder?No= 2 ptsSometimes= 1 ptsYes= 0
Select (B4)- State to what level you can use your arm for painless reasonably activities State to what level you can use your arm for painless reasonably activitiesWaist= 2Xiphoid (sternum)= 4Neck= 6Head= 8Above head= 10
Select (C)- Range of movement (leave this for the doctor or physiotherapist) (/40) Total (1 + 2 + 3 + 4) (C1)- FWD Flexion FWD Flexion0 - 30= 0 pts31 -60= 2 pts61 - 90= 491 - 120= 6121- 150= 8> 150= 10
Select (C2)- Abduction Abduction0 - 30= 0 pts31 -60= 2 pts61 - 90= 491 - 120= 6121- 150= 8> 150= 10
Select (C3)- External Rotation External RotationHand behind head & elbow forward= 2 ptsHand behind head & elbow back= 4 ptsHand above head & elbow forward= 6Hand above head & elbow back= 8Full elevation of arm= 10
Select (C4)- Internal Rotation Dorsum hand to Internal Rotation Dorsum hand toThigh= 0 ptsButtock= 2 ptsSI Joint= 4 ptsWaist= 6T 12= 8Between shoulder blades= 10
(D)- Power (/25) Points= average (kg) x 2 =
TOTAL (/100): A + B + C+ D
