| 1 |
How would you describe the worst pain you had from your shoulder? |
None |
1 |
4 |
|
|
Mild |
2 |
3 |
|
|
Moderate |
3 |
2 |
|
|
Severe |
4 |
1 |
|
|
Unbearable |
5 |
0 |
| 2 |
Have you had any trouble dressing yourself because of your shoulder? |
No trouble |
1 |
4 |
|
|
Little trouble |
2 |
3 |
|
|
Moderate trouble |
3 |
2 |
|
|
Extreme difficulty |
4 |
1 |
|
|
Impossible to do |
5 |
0 |
| 3 |
Have you had any trouble getting in and out of a car or using public transport because of your shoulder? |
No trouble |
1 |
4 |
|
|
Little trouble |
2 |
3 |
|
|
Moderate trouble |
3 |
2 |
|
|
Extreme difficulty |
4 |
1 |
|
|
Impossible to do |
5 |
0 |
| 4 |
Have you been able to use a knife and fork – at the same time? |
Yes, easily |
1 |
4 |
|
|
Little difficulty |
2 |
3 |
|
|
Moderate difficulty |
3 |
2 |
|
|
Extreme difficulty |
4 |
1 |
|
|
No, impossible |
5 |
0 |
| 5 |
Could you do household shopping on your own? |
Yes, easily |
1 |
4 |
|
|
Little difficulty |
2 |
3 |
|
|
Moderate difficulty |
3 |
2 |
|
|
Extreme difficulty |
4 |
1 |
|
|
No, impossible |
5 |
0 |
| 6 |
Could you carry a tray containing a plate of food across the room? |
Yes, easily |
1 |
4 |
|
|
Little difficulty |
2 |
3 |
|
|
Moderate difficulty |
3 |
2 |
|
|
Extreme difficulty |
4 |
1 |
|
|
No, impossible |
5 |
0 |
| 7 |
Could you brush/comb your hair with the affected arm? |
Yes, easily |
1 |
4 |
|
|
Little difficulty |
2 |
3 |
|
|
Moderate difficulty |
3 |
2 |
|
|
Extreme difficulty |
4 |
1 |
|
|
No, impossible |
5 |
0 |
| 8 |
How would you describe the pain you usually had from your shoulder? |
None |
1 |
4 |
|
|
Very mild |
2 |
3 |
|
|
Mild |
3 |
2 |
|
|
Moderate |
4 |
1 |
|
|
Severe |
5 |
0 |
| 9 |
Could you hang your clothes up in the wardrobe using the affected arm? |
Yes, easily |
1 |
4 |
|
|
Little difficulty |
2 |
3 |
|
|
Moderate difficulty |
3 |
2 |
|
|
Extreme difficulty |
4 |
1 |
|
|
No, impossible |
5 |
0 |
| 10 |
Have you been able to wash and dry yourself under both arms? |
Yes, easily |
1 |
4 |
|
|
Little difficulty |
2 |
3 |
|
|
Moderate difficulty |
3 |
2 |
|
|
Extreme difficulty |
4 |
1 |
|
|
No, impossible |
5 |
0 |
| 11 |
How much has the pain from your shoulder interfered with your usual work (including housework)? |
Not at all |
1 |
4 |
|
|
A little bit |
2 |
3 |
|
|
Moderately |
3 |
2 |
|
|
Greatly |
4 |
1 |
|
|
Totally |
5 |
0 |
| 12 |
Have you been troubled by pain from your shoulder in bed at night? |
No nights |
1 |
4 |
|
|
Only 1–2 nights |
2 |
3 |
|
|
Some nights |
3 |
2 |
|
|
Most nights |
4 |
1 |
|
|
Every night |
5 |
0 |
|
|
Total best score |
12 |
48 |
|
|
Total worst score |
60 |
0 |
