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Patient Functional Score Form
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Where did you find us?
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Which specialists do you see?
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Specialists Names and office #
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Who referred you?
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What is your preferred pharmacy
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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American Shoulder Elbow Surgeons (ASES) Score
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Pain Questionnaire
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What is the intensity of pain?
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Activities of Daily Living Questionnaire
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Is it difficult for you to put on a coat?
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Is it difficult for you to sleep on the affected side?
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Is it difficult for you to wash your back/do your bra?
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Is it difficult for you to manage the toilet?
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Is it difficult for you to comb your hair?
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Is it difficult for you to reach a high shelf?
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Is it difficult for you to lift 10 lbs (4.5 kg) above your shoulder?
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Is it difficult for you to throw a ball overhand?
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Is it difficult for you to do your usual work?
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Is it difficult for you to do your sports/leisure activities?
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