Date of Completion

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

1. During the past 4 weeks...

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

2. During the past 4 weeks...

Have you had any trouble dressing yourself because of your shoulder?
No trouble at all
A little bit of trouble
Moderate trouble
Extreme difficulty
Impossible to do

3. During the past 4 weeks...

Have you had any trouble getting in and out of a car or using public transport because of your shoulder?
No trouble at all
A little bit of trouble
Moderate trouble
Extreme difficulty
Impossible to do

4. During the past 4 weeks...

Have you been able to use a knife and fork - at the same time?
Yes easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible

5. During the past 4 weeks...

Could you do the household shopping on your own?
Yes easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible

6. During the past 4 weeks...

Could you carry a tray containing a plate of food across a room?
Yes easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible

7. During the past 4 weeks...

Could you brush/comb your hair with the affected arm?
Yes easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible

8. During the past 4 weeks...

How would you describe the pain you usually had from your shoulder?
None
Very mild
mild
Moderate
Severe

9. During the past 4 weeks...

Could you hang your clothes up in a wardrobe, using the affected arm?
Yes easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible

10. During the past 4 weeks...

Have you been able to wash and dry yourself under both arms?
Yes easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible

11. During the past 4 weeks...

How much has pain from your shoulder interfered with your usual work (including housework)??
Not at all
A little bit
Moderately
Greatly
Totally

12. During the past 4 weeks...

Have you been troubled by pain from your shoulder in bed at night?
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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There are two further small sections to this score. They are both optional. Just click below to select

SPORTS/PERFORMING ARTS MODULE
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.