Although some of the questions below may seem 'silly' or confusing, please try to provide an answer to EACH question.  Answer each question in regards to your AVERAGE day.  Thank you so much for your time completing this evaluation form.

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Rate your AVERAGE shoulder pain from 0 (No Pain) to 10 (Worst imaginable pain)

...Please chose the BEST answer... 0 1 2 3 4 5 6 7 8 9 10

In regards to your PAIN, please select the BEST answer choice:

...Please choose the BEST answer... No Pain Occasional and slight Present during HEAVY or particular activities only, little or no pain at rest; pain medicine occasionally Pain present during LIGHT activities, none or little at rest; weak pain meds frequently Present all of the time but bearable; strong medicine occasionally Pain present all of the time, unberable; strong medicine frequently

In regards to your FUNCTION, please select the BEST answer choice:

...Please choose the BEST answer... Normal activities Slight restrictions only, able to work above shoulder level Housework, driving, shopping possible. Able to do hair, dress / undress. Able to fasten bra (if applicable). Able to do light housework and most activities of daily living (toilet, bathing, etc) Only light activities possible Unable to use the arm

Are you satisfied with the RESULT from your shoulder surgery:

...Choose... Yes No

Has your shoulder motion become significantly BETTER or WORSE since your last visit with Dr. Brady:

...Choose... Better Stayed the Same Worse

Has your shoulder strength become significantly BETTER or WORSE since your last visit with Dr. Brady:

...Choose... Better Stayed the same Worse

Was your case a workers compensation case?

...Choose... Yes No

If it was a workers compensation case - has your case been settled?

...Choose... Yes No

Please answer YES or NO to each of the next 12 questions:

1. Is your shoulder comfortable with your arm at rest by your side?  ...Choose one... Yes No

2. Does your shoulder allow you to sleep comfortably?  ...Choose one... Yes No

3. Can you reach the small of your back to tuck in your shirt with your hand?  ...Choose one... Yes No

4. Can you place your hand behind your head with the elbow straight out to the side?  ...Choose one... Yes No

5. Can you place a coin on a shelf at shoulder level without bending your elbow?  ...Choose one... Yes No

6. Can you lift 1 lb (full pint container) to shoulder level without bending your elbow?  ...Choose one... Yes No

7. Can you lift 8 lb (full gallon container) to shoulder level without bending your elbow?  ...Choose one... Yes No

8. Can you carry 20 lb at your side with the affected extremity?  ...Choose one... Yes No

9. Do you think you can toss a softball underhand 10 yards with the affected extremity?  ...Choose one... Yes No

10. Do you think you can toss a softball overhand 20 yards with the affected extremity?  ...Choose one... Yes No

11. Can you wash the back of your opposite shoulder with the affected extremity?  ...Choose one... Yes No

12. Would your shoulder allow you to work full-time at your regular job?  ...Choose one... Yes No

Other comments or suggestions for Dr. Brady