Shoulder Muscle Knot Pain Assessment Form
Please complete this form to help assess your shoulder muscle knot pain. All questions are required for a thorough assessment.
Which shoulder is affected?
*
Left
Right
Both
How long have you experienced this pain?
*
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Please rate your current shoulder pain.
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
How would you describe the pain?
*
Aching
Sharp
Burning
Tingling
Stiffness
Other
When is the pain usually worst?
*
Morning
Afternoon
Evening
Night
No difference
What activities make the pain worse?
*
Lifting objects
Reaching overhead
Sleeping on affected side
Driving
Computer work
Other
What helps relieve your shoulder pain?
*
Rest
Ice or heat
Stretching
Massage
Medication
Other
Does the pain interfere with your daily activities?
*
Not at all
Mildly
Moderately
Severely
Have you tried any previous treatments for this pain?
*
Yes
No
Please describe any additional symptoms or details about your shoulder muscle knot pain.
Submit Assessment
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