Date of Completion

ASES Shoulder Score
Name
Age
Date
Patient's d.o.b
1. Usual Work
3. Do you have shoulder pain at night?
  • Yes
  • No
5. Do you take strong pain killers such as codeine, tramadol, or morphine?
  • Yes
  • No
2. Usual Sport/Leisure activity?
4. Do you take pain killers such as paracetamol (acetaminophen), diclofenac, or ibuprofen?
  • Yes
  • No
6. How many pills do you take on an average day?
7. Intensity of pain?
  • 10 9 8 7 6 5 4 3 2 1 0
    Pain as bad as it can be
    No pain at all
8. Is it difficult for you to put on a coat?
  • Unable to do
  • Very difficult to do
  • Somewhat difficult
  • Not difficult
10. Is it difficult for you to wash your back/do up bra?
  • Unable to do
  • Very difficult to do
  • Somewhat difficult
  • Not difficult
12. Is it difficult for you to comb your hair?
  • Unable to do
  • Very difficult to do
  • Somewhat difficult
  • Not difficult
14. Is it difficult for you to lift 10lbs. (4.5kg) above your shoulder?
  • Unable to do
  • Very difficult to do
  • Somewhat difficult
  • Not difficult
16. Is it difficult for you to do your usual work?
  • Unable to do
  • Very difficult to do
  • Somewhat difficult
  • Not difficult
9. Is it difficult for you to sleep on the affected side?
  • Unable to do
  • Very difficult to do
  • Somewhat difficult
  • Not difficult
11. Is it difficult for you manage toiletting?
  • Unable to do
  • Very difficult to do
  • Somewhat difficult
  • Not difficult
13. Is it difficult for you to reach a high shelf?
  • Unable to do
  • Very difficult to do
  • Somewhat difficult
  • Not difficult
15. Is it difficult for you to throw a ball overhand?
  • Unable to do
  • Very difficult to do
  • Somewhat difficult
  • Not difficult
17. Is it difficult for you to do your usual sport/leisure activity?
  • Unable to do
  • Very difficult to do
  • Somewhat difficult
  • Not difficult
Total ASES score is: %

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Reference:

American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness.Michener LA, McClure PW, Sennett BJ.J Shoulder Elbow Surg. 2002 Nov-Dec;11(6):587-94.