Shoulder Initial Evaluation

    Patient Name
    Date of Birth
    Which arm is dominant?
    Which arm is being evaluated?
    Where is the pain in your shoulder?

    In general, how would you describe your pain?
    How bad is your pain today? (0 = No pain 10 = Pain as bad as it can be)

    To what degree do you experience pain? Please choose the statement that applies to your pain.


    Please mark the statement that most describes how well you can use your injured arm. (Please only mark

    Please indicate the appropriate response to the following questions:

    1. Is your shoulder comfortable with your arm at rest by your side?
    2. Does your shoulder allow you to sleep comfortably?
    3. Can you reach the small of your back to tuck in your shirt with your hand?
    4. Can you place your hand behind your head with the elbow straight out to the side?
    5. Can you place a coin on a shelf at the level of your shoulder without bending your elbow?
    6. Can you lift 1 lb. (a full pint container) to the level of your shoulder without bending your elbow?
    7. Can you lift 8 lb. (a full gallon) to the level of the top of your head without bending your elbow?
    8. Can you carry 20 lbs. (a bag of potatoes) at your side with the affected extremity?
    9. Do you think you can toss a softball underhand 10 yards with the affected extremity?
    10. Do you think you can throw a softball overhand 20 yards with the affected extremity?
    11. Can you wash the back of your opposite shoulder with the affected extremity?
    12. Would your shoulder allow you to work full-time at your regular job?

    Choose the number that indicates your ability to do the following activities:
    0 = Unable to do | 1 = very difficult to do | 2 = somewhat difficult to do | 3 = not difficult to do

    1. Put on a coat
    2. Sleep on your painful or affected side
    3. Wash back/do bra in back
    4. Manage toileting
    5. Comb hair
    6. Reach a high shelf
    7. Lift 10 lbs. above shoulder
    8. Throw a ball overhand
    9. Do usual work
    10. Do usual sport

    What is the highest level that you can comfortably use your arm (mark the highest level)?

    Choose the types of upper extremity sports/activities in which you currently participate:

    1. Non-overhead & non-impact sports
    2. Non-overhead & high-impact sports
    3. Overhead sports
    4. Overhead sports with sudden stops

    Additional Comments:

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