Date of Completion

PROBLEMS WITH YOUR SHOULDER
Clinician Diagnosis
Patient's name (or ref)
Patient's d.o.b
INSTRUCTIONS Tick ( ) one box for every question.

1. During the last 6 months...

how many times has your shoulder slipped out of joint (or dislocated)?
Not at all in 6 months
1 or 2 times in 6 months
1 or 2 times in per months
1 or 2 times in per week
More often than 1 or 2 times/week

2. During the last 3 months...

have you had any trouble (or worry) with putting on a T-shirt or pullover because of your shoulder?
No trouble/ no worries
Slight trouble or worry
Moderate trouble or worry
Extreme difficulty
Impossible to do

3. During the last 3 months...

how would you describe the worst pain you have had from your shoulder?
None
Mild ache
Moderate
Severe
Unbearable

4. During the last 3 months...

how much has the problem with your shoulder interfered with your usual work? (including school or college work, or housework)
Not at all
A little bit
Moderate
Greatly
Totally

5. During the last 3 months...

have you avoided any activities due to worry about your shoulder – feared that it might slip out of joint?
No, not at all
Very occasionally
Some days
Most days or more han one activity
Every day or many activities

6. During the last 3 months...

has the problem with your shoulder prevented you from doing things that are important to you?
No, not at all
Very occasionally
Some days
Most days or more han one activity
Every day or many activities

7. During the last 3 months...

how much has the problem with your shoulder interfered with your social life? (including sexual activity – if applicable)
Not at all
Occasionally
Some days
Most days
Every day

8. During the past 4 weeks...

how much has the problem with your shoulder interfered with your sporting activities or hobbies?
Not at all
A little/ occasionally
Some of the time
Most of the time
All of the time

9. During the past 4 weeks...

how often has your shoulder been ‘on your mind’ – how often have you thought about it?
Never, or only if someone asks
Occasionally
Some days
Most days
Every day

10. During the past 4 weeks...

how much has the problem with your shoulder interfered with your ability – or willingness – to lift heavy objects?
Not at all
Occasionally
Some days
Most days
Every day

11. During the past 4 weeks...

how would you describe the pain you usually had from your shoulder?
None
Very mid
Mid
Moderately
Severe

12. During the past 4 weeks...

have you avoided lying in certain positions, in bed at night, because of your shoulder?
No nights
Only 1 or 2 nights
Some nights
Most nights
Every nights

Finally, please check back that you have answered each question. Thank you very much.

PROBLEMS WITH YOUR SHOULDER Score

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WORK MODULE

Reference: Waddell C, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993; 52:157-168.

Fritz JM, George S. Identifying Psychosocial Variables in Patients With Acute Work-Related Low Back Pain: The Importance of Fear-Avoidance Beliefs. Phys Ther. 2002; 82(10): 973-983.

Lethem J, Slade PD, Troup JDG, Bendey G. Outline of a fear avoidance model of exaggerated pain perceptions, Behav Res Ther. 1983;21:401-408.

Williamson E. Fear Avoidance Behavior Questionnaire. Austrailian Journal of Physiotherapy. 2006; 52: 149.

Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eck H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62: 36, 272.