Patient information

Shoulder Score Form

American Shoulder and Elbow Surgeons Score (ASES)

The form is sent via standard email security protocols. Alternatively, you may download a PDF Registration Form to our practice at admin@drpant.com.au.

"*" indicates required fields

Patient Details

Title*

Given Name*

Surname*

Current Occupation

Usual Sport/Leisure Activity

Pain Details

Which is your dominant hand/arm?*

Which is your affected shoulder?*

When do you experience shoulder pain?*

What is the intensity of pain?*

Pain Medication Details

Do you take pain killers such as paracetamol or ibuprofen?

Yes

Do you take strong pain killers such as codeine, tramadol, or endone?

Yes

How many pills do you take on an average day?

1-4

4-8

Activities of Daily Living Questionnaire

How difficult is it for you to:*

	Unable to do +0	Very difficult to do +1	Somewhat difficult +2	Not difficult +3
Put on a coat
Sleep on the affected side
Wash your back/do up bra
Manage toileting
Comb your hair
Reach a high shelf
Lift 5kg above your shoulder
Throw a ball overhand
Do your usual work
Do your usual sport/leisure activity

Subjective Shoulder Value (SSV)

How do you rate your overall shoulder function out of 100?*

E.g. 0 = No function; 50 = Half full function; 100 = Full function (normal shoulder)

Alternatively, if you have any further questions or would like a consultation with Dr Pant get in touch:

Injuries and Conditions

Shoulder Surgery

Case Studies

Patient Information

Patient information

Shoulder Score Form

American Shoulder and Elbow Surgeons Score (ASES)

Patient Details

Pain Details

Pain Medication Details

Activities of Daily Living Questionnaire

Subjective Shoulder Value (SSV)

Shoulder injuries and conditions

Shoulder surgery

Sydney Shoulder Unit

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Contact

Where

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