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Shoulder Quiz

Clinician's name (or ref)




Date of completion

Patient's name (or ref)

 
Please answer the following 12 multiple choice questions.
During the past 4 weeks......
1. How would you describe the worst pain you had from your shoulder?   7.Could you brush/comb your hair with the affected arm?
None   Yes, easily
mild   With little difficulty
Moderate   With moderate difficulty
Severe   With extreme difficulty
Unbearable   No, impossible
 
2. Have you had any trouble dressing yourself because of your shoulder?   8. How would you describe the pain you usually had from your shoulder?
No trouble at all   None
Little trouble   Very mild
Moderate trouble   Mild
Extreme difficulty   Moderate
Impossible to do   Severe
 
3. Have you had any trouble getting in and out of a car or using public transport because of your shoulder?   9. Could you hang your clothes up in a wardrobe, using the affected arm? (whichever you tend to use)
No trouble at all   Yes, easily
Very little trouble   With little difficulty
Moderate trouble   With moderate difficulty
Extreme difficulty   With great difficulty
Impossible to do   No, impossible
 
4. Have you been able to use a knife and fork at the same time?   10. Have you been able to wash and dry yourself under both arms?
Yes, easily   Yes, easily
With little difficulty   With little difficulty
With moderate difficulty   With moderate difficulty
With extreme difficulty   With extreme difficulty
No, impossible   No, impossible
 
5. Could you do the household shopping on your own?   11. How much has pain from your shoulder interfered with your usual work (including housework)?
Yes, easily   Not at all
With little difficulty   A little bit
With moderate difficulty   Moderately
With extreme difficulty   Greatly
No, impossible   Totally
 
6. Could you carry a tray containing a plate of food across a room?   12. Have you been troubled by pain from your shoulder in bed at night?
Yes, easily   No nights
With little difficulty   Only 1 or 2 nights
With moderate difficulty   Some nights
With extreme difficulty   Most nights
No, impossible   Every night

Shoulder Quiz Score is:


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Interpreting the Score
Score 0 to 19
May indicate severe shoulder arthritis. It is highly likely that you may well require some form of surgical intervention, contact your family physician for a consult with an Orthopaedic Surgeon.
Score 20 to 29

May indicate moderate to severe shoulder arthritis. See your family physician for an assessment and x-ray. Consider a consult with an Orthopaedic Surgeon.
Score 30 to 39

May indicate mild to moderate shoulder arthritis. Consider seeing you family physician for an assessment and possible x-ray. You may benefit from non-surgical treatment, such as exercise, weight loss, and /or anti-inflammatory medication

Score 40 to 48

May indicate satisfactory joint function. May not require any formal treatment.

Reference for Score:  Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of patients about total hip replacement. J Bone Joint Surg Br. 1996 Mar;78(2):185-90. Link