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* 1. Please type your name. Surname, First Name

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* 2. Who is your Physiotherapist?

Please place a mark on the line that best represents your experience during the last week attributable to your shoulder problem.

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* 3. Pain scale - How severe is your pain? Circle the number that best describes your pain where: 0 = no pain and 10 = the worst pain imaginable.

  0 None 5 6 7 8 9 10 The worst pain imaginable
At its worst?
When lying on the involved side?
Reaching for something on a high shelf?
Touching the back of your neck?
Pushing with the involved arm?

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* 4. Disability scale - How much difficulty do you have?   Circle the number that best describes your experience where: 0 = no difficulty and 10 = so difficult it requires help.

  0 No difficulty 5 6 7 8 9 10 So difficult it requires help
Washing your hair?
Washing your back?
Putting on an undershirt or jumper?
Putting on a shirt that buttons down the front?
Putting on your pants?
Placing an object on a high shelf?
Carrying a heavy object of 10 pounds (4.5 kilograms)?
Removing something from your back pocket?

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* 5. Scoring - for office use only - Score range 0 (worst), 100 (best), MDC = 13

This questionnaire is taken from: Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res. 1991 Dec;4(4):143-9.

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