Dr. Cantrell Shoulder Evaluation

Dr. Cantrell Shoulder Evaluation
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Date of Appointment *

Month Day Year
Date
Time of Appointment *

: Hour Minutes AM/PM Option
Are you having pain in your shoulder now?
Please mark your pain on the following diagram
Do you have pain in your shoulder at night?
Are you taking any pain medication?
Are you taking narcotic pain medication such as codeine?
On average, how many pills do you take per day? *
How bad is your pain today? 1 = no pain, 10 = extreme pain *
Does your shoulder feel unstable (as if it is going to dislocate)?
How unstable is your shoulder? 1 = very unstable, 10 = very stable *
Please consider the difficulty of completing the following actions with your RIGHT arm:
Put on a coat (right arm) *
Sleep on your side (right arm) *
Wash your back/hook your bra (right arm) *
Manage toiletries (right arm) *
Comb your hair (right arm) *
Reach a high shelf (right arm) *
Lift 10lbs above your shoulder (right arm) *
Throw a ball overhand (right arm) *
Do usual activities (right arm) *
Do usual sport (right arm) *
Please consider the difficulty of completing the following actions with your LEFT arm:
Put on a coat (left arm) *
Sleep on your side (left arm) *
Wash your back/hook your bra (left arm) *
Manage toiletries (left arm) *
Comb your hair (left arm) *
Reach a high shelf (left arm) *
Lift 10lbs above your shoulder (left arm) *
Throw a ball overhand (left arm) *
Do usual activities (left arm) *
Do usual sport (left arm) *
Should be Empty: