FILL OUT THIS Shoulder Pain Assessment
SURVEY BELOW!
so we can learn more about your needs
On a scale of 1(minimal pain) to 10 (severe pain) how would you rate your pain?
1
2
3
4
5
6
7
8
9
10
Where is the source of your pain? Choose all options that apply.
Neck
Back
Knee
Shoulder
Arms
Legs
Headache
Other
How did the pain begin? Choose all options that apply.
Accident at home
Vehicle accident
Accident at work/work related
It just began
After surgery
Came on gradually
Sports related
Other
What activities are you struggling with?
Sleeping
Reaching overhead
Getting Dressed
Driving
Household chores
Normal Work Duties
Physical Labor
Sports/Exercise
Have you seen any other doctors for treatment?
Chiropractor
Pain Management
Neurologist
Orthopaedic Surgeon
General/Family Doctor
Other
None
Have you had any surgeries for your existing pain or any other pain condition?
Yes
No
First Name
Last Name
Email
*
Phone
*
