Shoulder Disorders

Assessment Form for Treating Physician

Patient Name:_______________

Shoulder Injury or Illness Type: _______________________________

Date of Injury, if any:___________

Mechanism of Injury (contact, non-contact, fall, motor vehicle accident, work-related, etc.):

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Are there any other related injuries (cervical, thoracic spine, elbow, wrist, tendon, soft tissue, etc.)? Please describe:

_________________________________________________________________________

_________________________________________________________________________

Method of diagnosis (check all that apply):

• Clinical exam
• Imaging
• Operative findings

Pertinent diagnostic findings_______________

_____________________________________________

Treatment: __ Operative __ Non-operative

Description of treatment plan, including surgery dates:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

List of current medications related to injury:
_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Instability of shoulder on exam? __ Yes __ No

If “Yes,” please describe__________________________________________________

_________________________________________________________________________

Normal flexion/abduction strength? __ Yes __ No

Shoulder range of motion:

Flexion: _____ degrees

Abduction: _____ degrees

External Rotation: ______ degrees Internal Rotation: _____ degrees

Constant/Oxford/DASH Score, if available ____________________

WOSI Score, if available __________________

Does your patient have any further therapy and/or treatment needs?
__ Yes __ No

If “Yes,” please describe type and expected duration of therapy and/or treatment needs:

_________________________________________________________________________

_________________________________________________________________________

If “No,” is your patient at maximum medical improvement (MMI)?
__ Yes __ No

Can your patient perform the following tasks?*:

Crawl under obstacles:
__ Yes (unrestricted) __ Yes (with limitations) __ Unable to Perform

Climb a fence:
__ Yes (unrestricted) __ Yes (with limitations) __ Unable to Perform

Climb a ladder:
__ Yes (unrestricted) __ Yes (with limitations) __ Unable to Perform

Lifting, pushing or pulling with involved limb:

__ Yes (unrestricted) __ Yes (with limitations) __ Unable to Perform

Grip and hold objects:
__ Yes (unrestricted) __ Yes (with limitations) __ Unable to Perform

Do push-ups:
__ Yes (unrestricted) __ Yes (with limitations) __ Unable to Perform

Do overhead work:

__ Yes (unrestricted) __ Yes (with limitations) __ Unable to Perform

Does your patient have any other activity restrictions? __ Yes __ No

If “Yes,” please describe restrictions and if these are permanent or temporary restrictions:

_________________________________________________________________________

_________________________________________________________________________

Provide additional information, not included above, that may be helpful to the police physician.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

 

_______________________          __________

Signature of Physician     |     Date

___________________________      ___________       ___________

Printed Name of Physician    |    Phone#    |    Fax#