The Melbourne Shoulder Score Name Date Date of Birth Hand Dominance (please circle) Right Left Which shoulder is/was problematic (please circle) Right Left Both if both, please duplicate the form and fill in one for each shoulder. Indicate which is which Right Left When did symptoms develop in your shoulder Date (approx) How did these symptoms develop? (please give a very brief account) i.e. accident, sporting injury, overuse, and give some estimate of the amount of force which dislocated your shoulder on the first occasion, and on any subsequent occasions. What treatment have you had to date? (please circle and elaborate where indicated) None Rest Medication what type? over what period? Injections Physiotherapy how many? approx no. of visits name of physio Surgery Any Other Treatment (please add details) All the following questions relate to how your shoulder is now. If there has en any deterioration in your shoulder over the past year, please give a brief account here.
Section A Pain 1) Is there any activity which gives you pain in your shoulder? Yes No 2) How bad is your shoulder pain during the activity which causes problems with your shoulder? 3) How bad is your shoulder pain at rest during the day? 4) How bad is your shoulder pain at night? 5) Comments:
Section B Instability 1) How often on average, do you feel that your shoulder slips, slides or feels unstable? (please tick the box) More than once a day [ ] About once a day [ ] About once a week [ ] About once a month [ ] Less than once a month [ ] Never [ ] 2) How often does your shoulder actually come out of joint? More than once a day [ ] About once a day [ ] About once a week [ ] About once a month [ ] Less than once a month [ ] Never [ ] 3) Do you still feel anxious that your shoulder will actually come out of joint when playing sport? (tick only ONE box) Yes (I feel anxious my shoulder will come out of the joint when playing sports but I can still play all sports) [ ] Yes, I feel anxious about my shoulder and can only play modified sport due to my shoulder feeling unstable [ ] No, I do not feel anxious that my shoulder will come out of the joint, when playing sport [ ] Don t play sport at all cause of my shoulder [ ] Don t play sport for other reasons [ ] 4) Do you still feel anxious that your shoulder will actually come out of joint during everyday activities? Such as personal & household activities eg. dressing, washing & driving. Yes [ ] No [ ] 5) Are there daily personal & household activities such as dressing, washing and driving which you actually avoid cause of fear of dislocation or a feeling of instability of your shoulder? Yes [ ] No [ ] 6) Comments:
Section C Function Do you have anxiety about your shoulder either giving you pain or not ing properly located when you do the following things? E.g. * Tick Always = if you always have anxiety about your shoulder either giving you pain or not ing properly located when you do the following things. * Tick Never = if you never have anxiety about your shoulder either giving you pain or not ing properly located when you do the following things. If you are unable to do any of these activities cause of a problem with your shoulder, tick the Unable box. Always Mostly Sometimes Rarely Never Unable 1) Throw a ball? [ ] [ ] [ ] [ ] [ ] [ ] 2) Reach up & hind your head? [ ] [ ] [ ] [ ] [ ] [ ] 3) Reach up & hind your back? [ ] [ ] [ ] [ ] [ ] [ ] 4) In d at night? [ ] [ ] [ ] [ ] [ ] [ ] 5) Pulling a jumper on or off? [ ] [ ] [ ] [ ] [ ] [ ] 6) Lifting a weight (~10lbs) [ ] [ ] [ ] [ ] [ ] [ ] above your shoulder? 7) Doing pushups or nch press? [ ] [ ] [ ] [ ] [ ] [ ] 8) Carrying heavy objects by your [ ] [ ] [ ] [ ] [ ] [ ] side? 9) Comments:
Section D Occupation and Sporting Demands Always Mostly Sometimes Rarely Never Unable 1) Does your shoulder get tired when writing for more than a few minutes? [ ] [ ] [ ] [ ] [ ] [ ] 2) Does you shoulder get tired when working at or above shoulder height? [ ] [ ] [ ] [ ] [ ] [ ] 3) Do you have problems with sudden or unguarded movements? [ ] [ ] [ ] [ ] [ ] [ ] Always Mostly Sometimes Rarely Unable 4) Can you perform all the tasks in your [ ] [ ] [ ] [ ] [ ] occupation due to your shoulder? (Including student/home duties) (If unemployed answer as for your previous occupational demands) 5) Can you play sport [ ] [ ] [ ] [ ] [ ] to your usual level cause of your shoulder? SECTION E Do these questions adequately descri the problems that you have with your shoulder, or are there other problems which you experience? SECTION F Overall, what score would you give your shoulder (%) compared to what you consider a normal shoulder. % End of Questionnaire. Thank you very much for completing this.