Shoulder Evaluation Form

Name

Date

Age

Right or Left Handed?

Right Handed

Left Handed

Involved Shoulder?

Right

Left

Both

Which is worse?

Right Worse

Left Worse

When did problem start?

Injury?

Yes

No

What happened to shoulder? (i.e. fall directly onto shoulder, landed on outstretched arm,)

Do you have any of the following? (CTRL+Click for multiple selection)

Location of pain: (CTRL+Click for multiple selection)

How severe is the pain on average? (none) 0 1 2 3 4 5 6 7 8 9 10 (extreme)

What makes pain worse? (i.e. arm out to side, throwing)

What makes pain better?

Have you had any of the following tests for this condition? (CTRL+Click for multiple selection)

If "Other" was selected above, please describe.

Previous shoulder injuries/dates

Medications taken for this? (CTRL+Click for multiple selection)

If you selected "Other" above, please describe.

Injections? Please select all that apply. (CTRL+Click for multiple selection)

If "Other" is selected above, please describe.

Percent improvement with injection(s)

Physical Therapy?

Yes

No

If "Yes" when and did you find it helpful?

Surgery?

Yes

No

If "Yes" please provide date & surgeon of surgery performed.

Sports/recreational activities

Level of sport currently: (CTRL+Click for multiple selection)

If "Other" is selected above, please describe.

Occupation

Current School/Grade Level

Goals after treatment for this problem

Position?

Do you play year round?

Yes

No

How many teams?

When last played?

Average pitch count?

Which part of throwing cycle causes pain? (Select all that apply. CTRL+Click for multiple selection)

Shoulder Evaluation Form

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For Baseball Players

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