Help us assess your response to treatment Full Name *Email Address *Please answer the below questions based on the past 4 weeks.How would you describe the worst pain you had from your shoulder?NoneMildModerateSevereUnbearableHow would you describe the pain you usually had from your shoulder?NoneVery MildMildModerateSevereHave you had any trouble dressing yourself because of your shoulder?No trouble at allA little bit of troubleModerate troubleExtreme difficultyImpossible to doHave you had any trouble getting in and out of a car or using public transport because of your shoulder?No trouble at allA little bit of troubleModerate troubleExtreme difficultyImpossible to doHave you been able to use a knife and fork - at the same time?No trouble at allA little bit of troubleModerate troubleExtreme difficultyImpossible to doCould you do the household shopping on your own?No trouble at allA little bit of troubleModerate troubleExtreme difficultyImpossible to doCould you carry a tray containing a plate of food across a room?No trouble at allA little bit of troubleModerate troubleExtreme difficultyImpossible to doCould you brush/comb your hair with the affected arm?No trouble at allA little bit of troubleModerate troubleExtreme difficultyImpossible to doCould you hang your clothes up in a wardrobe, using the affected arm?No trouble at allA little bit of troubleModerate troubleExtreme difficultyImpossible to doHave you been able to wash and dry yourself under both arms?No trouble at allA little bit of troubleModerate troubleExtreme difficultyImpossible to doHow much has pain from your shoulder interfered with your usual work (including housework)?Not at allA little bitModeratelyGreatlyTotallyHave you been troubled by pain from your shoulder in bed at night?No nightsOnly 1 or 2 nightsSome nightsMost nightsEvery nightSubmitPlease do not fill in this field.
