Shoulder Pain Symptoms and Immobility Checklist

Symptoms Checklist

Don't Wait!

Shoulder pain can be symptomatic of many illnesses or diseases. Consult a physician immediately if:

Your shoulder pain is accompanied by chest pain, nausea or shortness of breath.

Your shoulder pain is a result of an accident, fall or other injury.

Your pain lasts more than 7 to 10 days.

Your pain is becoming more severe.

You have questions or concerns about your shoulder pain.

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2	On a scale of 1-4, indicate your pain level: 1: no pain 2: mild pain 3: moderate pain 4: severe pain
3	Have you had a recent injury, fall or other accident? Yes No
4	Do you repeatedly move your shoulder in the same way on a daily basis (such as in sporting activities)? Yes No
5	Has your shoulder been treated with any of the following? surgery injections physical therapy medications acupuncture chiropractic none of the above
6	Did the pain start slowly or suddenly? Slowly Suddenly
7	How long has your pain lasted?
8	Does the pain travel from your shoulder to other parts of your body? Yes No
9	When do you experience pain (check any that apply): at rest during activity at night (wakes me up) raising my arm above my shoulder
10	Have you noticed a loss of strength? Yes No
11	Do you feel you have lost mobility for doing things like putting your hand in your back pocket, combing your hair or putting a coat on? Yes No
12	Does it hurt when you lie on the affected side? Yes No
13	Does your shoulder feel like it could "pop out" of the socket? Yes No
14	Do you hear a "clicking" sound when you move your shoulder? Yes No
15	Is your shoulder tender to the touch? Yes No
16	Did you have neck pain before you had shoulder pain? Yes No
	If yes, do you have a numbness or tingling? Yes No
17	Is the pain worse when you move your neck? Yes No
18	Does your biceps muscle (front of upper arm) look funny (i.e. short and enlarged)? Yes No
19	Do you have numbness in your fingers? Yes No
20	Are you right handed or left handed? Right handed Left handed
21	Include any additional information you think may be helpful for your doctor or surgeon: