Patient information

Shoulder Score Form

American Shoulder and Elbow Surgeons Score (ASES)

"*" indicates required fields

Patient Details

Pain Details

Pain Medication Details

Do you take pain killers such as paracetamol or ibuprofen?
Do you take strong pain killers such as codeine, tramadol, or endone?
How many pills do you take on an average day?

Activities of Daily Living Questionnaire

Unable to do +0Very difficult to do +1Somewhat difficult +2Not 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)

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

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