Shoulder Well Assessment
Welcome to the Shoulder Wellness Assessment! This tool offers a quick and thorough evaluation of your
Shoulder health. By examining key aspects of functionality, strength, and mobility, you'll gain
essential insights to help maintain and enhance your Shoulder wellness. Start now to take the first
step towards optimal Shoulder health!
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Patient Identifier:
Date completed:
Section 1: Pain Intensity
I have no pain at the moment
The pain is very mild at the moment
The pain is moderate at the moment
The pain is fairly severe at the moment
The pain is very severe at the moment
The pain is the worst imaginable at the moment
Section 2: Personal Care (Washing, Dressing, etc.)
I can look after myself normally without
causing extra pain
I can look after myself normally but it
causes extra pain
It is painful to look after myself but I am
slow and careful
I need some help but can manage most of my
personal care
I need help every day in most aspects of
self care
I do not get dressed, I wash with difficulty and
stay in bed
Section 3: Lifting
I can lift heavy weights without extra pain
I can lift heavy weights but it gives extra
pain
Pain prevents me from lifting heavy weights
off the floor but I can manage if they are conveniently positioned (e.g. on a table)
Pain prevents me from lifting heavy weights
but I can manage light to medium weights if they are conveniently positioned
I can lift very light weights
I cannot lift or carry anything at all
Section 4: Walking
Pain does not prevent me from walking any
distance
Pain prevents me from walking more than 1
mile
Pain prevents me from walking more than 1/2
mile
Pain prevents me from walking more than 1/4
mile
I can walk only with crutches or a cane
I am in bed most of the time and have to crawl
to the toilet
Section 5: Sitting
I can sit in any chair as long as I like
I can only sit in my favorite chair as long
as I like
Pain prevents me from sitting more than 1
hour
Pain prevents me from sitting more than 1/2
hour
Pain prevents me from sitting more than 10
minutes
I avoid sitting because it increases pain
immediately
Section 6: Forward Flexion
31-60 degrees
61-90 degrees
91-120 degrees
121-150 degrees
151-180 degrees
I avoid Standing because it increases pain
immediately
Section 7: Sleeping
I can sleep as I like
I can only sleep as long
as I like
Pain prevents me from Sleeping more than 1
hour
Pain prevents me from Sleeping more than 1/2
hour
Pain prevents me from Sleeping more than 10
minutes
I avoid Sleeping because it increases pain
immediately
Section 8: External Rotation
Hand behind Head, Elbow forward
Hand behind Head, Elbow back
Hand to top of Head, Elbow forward
Hand to top of Head, Elbow back -
Full Elevation
I avoid because it increases pain
immediately
Section 9: Social Life
I can involve as I like
I can only involve as long
as I like
Pain prevents me from involving more peoples
Pain prevents me from involving more peoples comfort
Pain prevents me from involving more peoples Severe
I avoid involving because it increases pain
immediately
Section 10: Travelling
I can travel as I like
I can only travel as long
as I like
Pain prevents me from Travelling more than 1
hour
Pain prevents me from Travelling more than 2
day
Pain prevents me from Travelling more than 10
days
I avoid Travelling because it increases pain
immediately
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