NJR Total Shoulder Replacement Questionnaire

Total Shoulder Replacement Questionnaire

We would like you to score yourself on the following 12 questions. Each question is scored from 4 to 0, from least to most difficulty or severity: 4 being the least difficult/severe and 0 being the most difficult/severe. Please select the number which best describes yourself OVER THE LAST 4 WEEKS.
Patient Name
Email Address
Home Address
Date of Birth
Operating Surgeon

Please select the SIDE on which your surgery was performed

Left
Right

Q1	How would you describe the worst pain you have had from your operated on shoulder?
		4. None 3. Mild 2. Moderate 1. Severe 0. Unbearable
Q2	How would you describe the pain you usually have from your operated on shoulder?
		4. None 3. Very mild 2. Moderate 1. Severe 0. Unbearable
Q3	Have you had any trouble getting in and out of a car or using public transport because of your operated on shoulder?
		4. No trouble at all 3. A little bit of trouble 2. Moderate trouble 1. Extreme difficulty 0. Impossible to do
Q4	Have you been able to use a knife and fork at the same time?
		4. Yes, easily 3. With little difficulty 2. With moderate difficulty 1. With extreme difficulty 0. No, impossible
Q5	Could you do the household shopping on your own?
		4. Yes, easily 3. With little difficulty 2. With moderate difficulty 1. With extreme difficulty 0. No, impossible
Q6	Could you carry a tray containing a plate of food across a room?
		4. Yes, easily 3. With little difficulty 2. With moderate difficulty 1. With extreme difficulty 0. No, impossible
Q7	Could you brush/comb your hair with the operated on arm?
		4. Yes, easily 3. With little difficulty 2. With moderate difficulty 1. With extreme difficulty 0. No, impossible
Q8	Have you had any trouble dressing yourself because of your operated on shoulder?
		4. No trouble at all 3. A little bit of trouble 2. Moderate trouble 1. Extreme difficulty 0. Impossible to do
Q9	Could you hang your clothes up in a wardrobe - using the operated on arm?
		4. Yes, easily 3. With little difficulty 2. With moderate difficulty 1. With extreme difficulty 0. No, impossible
Q10	Have you been able to wash and dry yourself under both arms?
		4. Yes, easily 3. With little difficulty 2. With moderate difficulty 1. With extreme difficulty 0. No, impossible
Q11	How much has pain from your operated on shoulder interfered with your usual work or recreational activities (including housework?
		4. Not at all 3. A little bit 2. Moderately 1. Greatly 0. Totally
Q12	Have you been troubled by pain from your operated on shoulder in bed at night?
		4. No nights 3. Only 1 or 2 nights 2. Some nights 1. Most nights 0. Every nights

Additional Information...

Have you at any time been hospitalised because...
The artificial joint dislocated? (enter approx year)
The joint became infected? (enter approx year)
Or for any other reason related to the artificial joint?
Hospital admitted to:
I wish to receive a progress report on the study

NB If there are reasons other than the operation which would stop you doing one of the tasks listed, try to answer the question from the joint replacement aspect alone.