Shoulder Quiz

Clinician’s name (or ref) June 13, 2019
Date of completionPatient’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:

This page cannot be saved by us due to patient data protection so,
before closing this window, please print the filled in form for your records.
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.