APPENDIX #.

Survey Questionnaire
Shoulder Surgery Expectations Survey
 HULC Shoulder Package

Name: ____________ Date______________ Study ID: __________ side being

treated: _____________

Circle the number that best describes your pain. 0 = no pain 10= worst pain imaginable

1. At its worst? 0 1 2 3 4 5 6 7 8 9 10
2. When lysing on the involved side? 0 1 2 3 4 5 6 7 8 9 10
3. Reaching for something on
a high shelf? 0 1 2 3 4 5 6 7 8 9 10
4. Touching the back of neck? 0 1 2 3 4 5 6 7 8 9 10
5. Pushing with the involved side? 0 1 2 3 4 5 6 7 8 9 10

Circle the number in the box that indicates your ability to do the following:

0 = Unable to do; 1 = Very difficult to do; 2 = Somewhat difficult; 3 = Not difficult

Affected side Unaffected side
1. Put on a coat 0 1 2 3 0 1 2 3
2. Sleep on your painful or affected side 0 1 2 3 0 1 2 3
3. Wash back / do up bra in back 0 1 2 3 0 1 2 3
4. Manage toileting 0 1 2 3 0 1 2 3
5. Comb hair 0 1 2 3 0 1 2 3
6. Reach a high shelf 0 1 2 3 0 1 2 3
7. Lift 10 lbs (4.5kg). above shoulder 0 1 2 3 0 1 2 3
8. Throw a ball overhand 0 1 2 3 0 1 2 3
9. Do usual work – List: ________________ 0 1 2 3 0 1 2 3
10. Do usual sport / leisure activity 0 1 2 3 0 1 2 3
List: ________________
Circle your Intensity of pain:
10 9 8 7 6 5 4 3 2 1 0

Pain as bad as it can be No pain at

all YES NO

1. Is your shoulder comfortable with your arm at rest by your side Y N

2. Does your shoulder allow you to sleep comfortably? Y N
3. Can you reach the small of your back to tuck in your shirt with your hand? Y N
4. Can you place your hand behind your head with your elbow straight out to the side? Y N
5. Can you place a coin on a shelf at the level of your shoulder without bending your elbow? Y N
6. Can you lift one pound (a full pint container) to the level of your shoulder without bending Y N
your elbow
7. Can you lift eight pounds (a full gallon container) to the level of your shoulder without Y N
bending your elbow?
8. Can you carry twenty pounds (9kg) at your side with your affected arm? Y N
 9. Do you think you can toss a softball under-hand twenty yards with your affected arm? Y N
10. Do you think you can toss a softball over-hand twenty yards with your affected arm? Y N
11. Can you wash the back of your opposite shoulder with your affected arm? Y N
12. Would your shoulder allow you to work full-time at your regular job? Y N

SANE PASS

On a scale from 0 to 100, how would you rate Considering everything, if your shoulder problem were to
your hand/wrist today (with 100 being stay like it is now, would you consider that acceptable?
normal)? ___________ □ Yes □ No

If this is a follow-up visit, answer the following 2 questions:

How much you have changed since you began treatment? (Circle one)
-5 -4 -3 -2 -1 0 1 2 3 4 5
Very much worse Unchanged Completely Recovered

Are you satisfied with your surgery/treatment?

0 1 2 3 4 5 6 7 8 9 10
Not at all satisfied Very satisfied

By placing a tick in one box in each group below, indicate which statements best describes your health state TODAY.
Mobility Self-Care
 I have no problems walking about  I have no problems washing or dressing myself
 I have slight problems walking about  I have slight problems washing or dressing myself
 I have moderate problems walking about  I have moderate problems washing or dressing
 I have severe problems walking about myself
 I am unable to walk about  I have severe problems washing or dressing myself
 I am unable to wash or dress myself
Usual Activities (e.g. work, study, house work, Pain/discomfort
family or leisure activities)  I have no pain or discomfort
 I have no problems doing my usual activities  I have slight pain or discomfort
 I have slight problems doing my usual  I have moderate pain or discomfort
activities  I have severe pain or discomfort
 I have moderate problems doing my usual  I have extreme pain or discomfort
activities Anxiety/Depression
 I have severe problems doing my usual  I am not anxious or depressed
activities  I am slightly anxious or depressed
 I am unable to do my usual activities  I am moderately anxious or depressed
 I am severely anxious or depressed
 I am extremely anxious or depressed
Please mark a slash (“X”) on the scale to indicate how your health is TODAY
The WORST health |---- l ---- l ----l ---- l ---- l ---- l ---- l ---- l ---- l ---- l ---- l ----l ---- l ----l ---- l ---- l ---- l ---- l ---- l
----| The BEST health
You can imagine 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
90 95 100 You can imagine

ONLY COMPLETE IF YOU HAVE A ROTATOR CUFF PROBLEM

The following section concerns the amount that your shoulder problem has affected or changed
your lifestyle. Please indicate the appropriate amount for the past week by circling a number. 0 =
No Diffuclty 10 = Extreme Difficulty

1. How much difficulty do you have sleeping because of your shoulder?

0 1 2 3 4 5 6 7 8 9 10
2. How much difficulty have you experienced with styling your hair because of your
shoulder?

0 1 2 3 4 5 6 7 8 9 10
3. How much difficulty do you have dressing or undressing?

0 1 2 3 4 5 6 7 8 9 10
4. How much difficulty do you experience in daily activities about the house or yard?

0 1 2 3 4 5 6 7 8 9 10
5. How much difficulty do you experience working above the shoulder?

0 1 2 3 4 5 6 7 8 9 10
6. How much do you use your unaffected arm to compensate for the injured arm?

0 1 2 3 4 5 6 7 8 9 10
7. How much difficulty do you experience lifting heavy objects at or below shoulder
level?

0 1 2 3 4 5 6 7 8 9 10
Hopkins Rehabilitation Engagement Rating Scale