SHOULDER PAIN & DISABILITY INDEX Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *Date of Birth *Email Address *Phone Number *Please place a mark on the line that best represents your experience during the last week attributable to your shoulder problem. Pain scale How severe is your pain? Pick the number that best describes your pain where: 0 = no pain and 10 = the worst pain imaginable.At its worst? Selected Value: 0 When lying on the involved side? Selected Value: 0 Reaching for something on a high shelf? Selected Value: 0 Touching the back of your neck? Selected Value: 0 Pushing with the involved arm? Selected Value: 0 shelf? pounds Carrying Disability scale How much difficulty do you have? Circle the number that best describes your experience where: 0 = no difficulty and 10 = so difficult it requires help.Washing your hair? Selected Value: 0 Washing your back? Selected Value: 0 Putting on an undershirt or jumper? Selected Value: 0 Putting on a shirt that buttons down the front? Selected Value: 0 Putting on your pants? Selected Value: 0 Placing an object on a high shelf? Selected Value: 0 Carrying a heavy object of 10 pounds (4.5 kilograms)? Selected Value: 0 Removing something from your back pocket? Selected Value: 0 Submit PAIN IS NOT A LIFESTYLE Get your quality of life back today. BOOK APPOINTMENT
