Pre-Surgery shoulder Questionnaire Name *Email Address *1.How would you describe the worst pain you had from your shoulder? NoneMildModerateSevereUnbearable2. Have you had any trouble dressing yourself because of your shoulder? No trouble at allLittle troubleModerate troubleExtreme difficulty Impossible to do3. Have you had any trouble getting in and out of a car or using public transport because of your shoulder? No trouble at allVery little troubleModerate troubleExtreme difficultyImpossible to do4. Have you been able to use a knife and fork at the same time?Yes, easilyWith little difficultyWith moderate difficultyWith extreme difficulty Not at all - severe on walking5. Could you do the household shopping on your own? Yes, easily With little difficultyWith moderate difficultyWith extreme difficultyNo, impossible6. Could you carry a tray containing a plate of food across a room?Yes, easilyWith little difficultyWith moderate difficultyWith extreme difficultyNo, impossible7.Could you brush/comb your hair with the affected arm?Yes, easilyWith little difficultyWith moderate difficultyWith extreme difficultyNo, impossible8. How would you describe the pain you usually had from your shoulder?NoneVery mildMildModerateSevere9. Could you hang your clothes up in a wardrobe, using the affected arm? (whichever you tend to use)Yes, easilyWith little difficultyWith moderate difficultyWith great difficultyNo, impossible10. Have you been able to wash and dry yourself under both arms?Yes, easilyWith little difficultyWith moderate difficultyWith extreme difficultyNo, impossible11. How much has pain from your shoulder interfered with your usual work (including housework)?Not at allA little bitModeratelyGreatlyTotally12. Have you been troubled by pain from your shoulder in bed at night?No nightsOnly 1 or 2 nightsSome nightsMost nightsEvery nightPre-Surgery Shoulder ScoreSend Shoulder Score
