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Date of completion
ASES Shoulder Score    
Name Age Date
 
1. Usual Work   2. Usual Sport/Leisure activity?
 

 

3. Do you have shoulder pain at night?   4) Do you take pain killers such as paracetamol (acetaminophen), diclofenac, or ibuprofen?
Yes   Yes
No   No
     
5) Do you take strong pain killers such as codeine, tramadol, or morphine?   6) How many pills do you take on an average day?
Yes  
No  

 

7) Intensity of pain?
10 9 8 7 6 5 4 3 2 1 0
Pain as bad as it can be
No pain at all
     
8) Is it difficult for you to put on a coat?   9) Is it difficult for you to sleep on the affected side?
Unable to do   Unable to do
Very difficult to do   Very difficult to do
Somewhat difficult   Somewhat difficult
Not difficult   Not difficult

 

10) Is it difficult for you to wash your back/do up bra?   11) Is it difficult for you manage toiletting?
Unable to do   Unable to do
Very difficult to do   Very difficult to do
Somewhat difficult   Somewhat difficult
Not difficult   Not difficult

 

12) Is it difficult for you to comb your hair?   13) Is it difficult for you to reach a high shelf?
Unable to do   Unable to do
Very difficult to do   Very difficult to do
Somewhat difficult   Somewhat difficult
Not difficult   Not difficult

 

14) Is it difficult for you to lift 10lbs. (4.5kg) above your shoulder?   15) Is it difficult for you to throw a ball overhand?
Unable to do   Unable to do
Very difficult to do   Very difficult to do
Somewhat difficult   Somewhat difficult
Not difficult   Not difficult

 

16) Is it difficult for you to do your usual work?   17) Is it difficult for you to do your usual sport/leisure activity?
Unable to do   Unable to do
Very difficult to do   Very difficult to do
Somewhat difficult   Somewhat difficult
Not difficult   Not difficult

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The Total ASES score is:
Page design : Aaron Rooney
 
Reference : American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness.Michener LA, McClure PW, Sennett BJ.J Shoulder Elbow Surg. 2002 Nov-Dec;11(6):587-94.