Get Shoulder Evaluation Form

Completing the Shoulder Evaluation Form online is an essential step in assessing your shoulder condition. This guide will provide you with clear, step-by-step instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete the Shoulder Evaluation Form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering your name in the designated field at the top of the form.
3. Indicate which shoulder or extremity is causing you discomfort by selecting 'Right,' 'Left,' or 'Both.' If both shoulders are affected, specify which one is more painful by entering 'R' for right or 'L' for left.
4. Provide information on how long you have been experiencing the issue in the space provided.
5. Answer whether you have sustained an injury to the shoulder(s) by choosing 'Yes' or 'No.'
6. Indicate if the injury occurred at work by selecting 'Yes' or 'No.'
7. Describe the injury and/or current symptoms in the text box below. Be thorough to assist the evaluation.
8. Respond to questions about pain when raising your arms overhead and reaching behind your back by checking the appropriate boxes for 'Right' or 'Left.'
9. Rate your pain levels for both shoulders on a scale from 1 to 10, where 1 indicates no pain and 10 indicates incapacitating pain.
10. Document any pain medication you use and how often you take it in the spaces provided.
11. Rate any shoulder weakness on the same scale of 1 to 10.
12. Indicate if your shoulder feels unstable and rate the degree of instability if applicable.
13. Provide information on any clicking, grinding, popping, or snapping sounds you hear from your shoulder.
14. Indicate whether you experience pain at night for either shoulder.
15. Answer if you have neck pain and if you experience numbness or tingling in your arms.
16. Rate your ability to perform daily activities on a scale from 1 (unable) to 4 (normal) for each activity listed.
17. Once all information is filled out, review the entries for accuracy and completeness.
18. Save your changes, and if needed, download, print, or share the completed form.

Complete your Shoulder Evaluation Form online today to ensure a thorough assessment of your condition.