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Orthopaedic Associates Zanesville Shoulder Pain Questionaire

This shoulder pain questionnaire collects information about a patient's shoulder condition, including which shoulder is affected, injury details, symptoms, pain levels, aggravating/relieving factors, previous treatments, and current medications. It asks the patient to describe their pain, identify activities that increase/decrease it, note if it radiates, and list any other symptoms like clicking, weakness, or stiffness. Treatment history is explored along with whether their condition is improving, worsening, or staying the same. Prior imaging tests and current medications are also documented.

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Majid Jahangeer Khan
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57 views3 pages

Orthopaedic Associates Zanesville Shoulder Pain Questionaire

This shoulder pain questionnaire collects information about a patient's shoulder condition, including which shoulder is affected, injury details, symptoms, pain levels, aggravating/relieving factors, previous treatments, and current medications. It asks the patient to describe their pain, identify activities that increase/decrease it, note if it radiates, and list any other symptoms like clicking, weakness, or stiffness. Treatment history is explored along with whether their condition is improving, worsening, or staying the same. Prior imaging tests and current medications are also documented.

Uploaded by

Majid Jahangeer Khan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SHOULDER PAIN QUESTIONNAIRE

Patient Name: DOB: Date:

 Which shoulder is bothering you? Left Right Both


 Are you left handed or right handed? Left Right
 What type of work do you do?
 Did your shoulder pain start with a specific injury? Yes or No
o If “yes”: Date of injury:
o Mechanism of injury:
o Did you feel a pop or a snap with the injury? Yes or No
o Is the injury work related? Yes or No
o Is it the result of a car accident? Yes or No
 If there was no injury, did the pain start with a particular activity (such as baseball, tennis,
painting, etc.)?
o If “yes”, what started the pain?
 If you did not have an injury, when did the pain start?
 What are your primary sports and/or activities?
 How do you describe your pain?
 How severe is it? (1-10 scale)
 Have you dropped items due to a shoulder condition? Yes or No
 Do any of the following increase your pain?
o Sleeping on the affected shoulder: Yes Minimally No
o Lifting your arm overhead: Yes Minimally No
o Reaching out from your side: Yes Minimally No
o Reaching behind your back: Yes Minimally No
o Throwing motion: Yes Minimally No
o Participating in sports: Yes Minimally No
o Work activities: Yes Minimally No
o Is there anything else that increases your pain?

 Do any of the following decrease your pain?


o Rest: Yes Minimally No
o Ice: Yes Minimally No
o Heat: Yes Minimally No
o Over the counter meds (Tylenol/Advil) Yes Minimally No
o Prescription meds: Yes Minimally No
o Is there anything else that decreases your pain?

 Does the pain move down your arm or up into your neck? Yes or No
 Do you have shoulder pain at night? Yes or No
 Do you have any of the following symptoms?
SHOULDER PAIN QUESTIONNAIRE (cont’d)

o Clicking, popping, or grinding in your shoulder: Yes or No


o Weakness of your shoulder: Yes or No
o Weakness of your arm, elbow or hand: Yes or No
o Numbness or tingling in your arm or hand: Yes or No
o Stiffness of your shoulder: Yes or No
o Persistent or recurrent neck pain: Yes or No
o Are there any other symptoms regarding your shoulder that we should know about?

 Have you had any previous surgery to your shoulder? Yes or No


If “yes” what type of surgery did you have and when did you have the surgery?

 Have you had any previous treatment for your shoulder pain such as:
o Cortisone injections: Yes or No
o Home exercises Yes or No
When? How long?
o Physical Therapy: Yes or No
When? How long?
o Chiropractic care: Yes or No
o Acupuncture: Yes or No
o Any other previous treatment for your shoulder pain?

 In general are your symptoms getting better, getting worse, or staying about the same?

 Have you had any x-rays taken of your shoulder? Yes or No


o If yes: Date of x-ray:
X-ray facility:
 Have you had an MRI of your shoulder? Yes or No
o If yes: Date of MRI:
MRI facility:
SHOULDER PAIN QUESTIONNAIRE (cont’d)

CURRENT MEDICATIONS (include non-prescription meds and herbal supplements, etc.


(If more than 14 medications, please list on a separate sheet)

Name of Medication Dose How Often? Name of Medication Dose How Often?

ALLERGIES:
Medications None Yes

(Please describe)

Latex None Yes


Yes
Metal None

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