Shoulder Pain Check-In Form
Please answer the following questions to help us assess your shoulder pain.
Full Name
*
First Name
Last Name
Date of Check-In
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which shoulder is affected?
*
Left
Right
Both
How would you rate your shoulder pain today?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
0 is No pain, 10 is Worst pain imaginable
How long have you been experiencing this pain?
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
What activities make your shoulder pain worse?
Lifting objects
Reaching overhead
Sleeping on affected side
Driving
Other
Have you tried any treatments or medications for your shoulder pain?
*
Yes
No
If yes, please specify what you have tried.
Are you experiencing any of the following symptoms?
Numbness or tingling
Weakness
Swelling
None of the above
Submit
Should be Empty: