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Questionnaire for Shoulder Research

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Shoulder Research Center Screening Questionnaire

Please complete the questions below to determine if you are eligible for participation in our current shoulder study. Your personal information will be kept confidential and protected in accordance with HIPPA regulations. Thank you for your interest.

Dominant Hand:
Shoulder Pain:
Involved Side:
Please enter a number from 1 to 9.
How often do you have shoulder pain?
Do you have pain when you raise your arm?
Do you have a history of any shoulder fractures?
Do you have a history of any shoulder dislocation in the past three months?
Do you have a history of rotator cuff tears or surgery?
Have you had any shoulder injections in the past three months?
Do you have any notable neck pain?
Do you have a diagnosed neck condition?
Is your shoulder pain made notably worse with normal neck movements?
Do you have any pain in your elbows or hands?
Do you have any known uncontrolled high blood pressure or any other cardiac or neurologic issues?
Do you have any implanted medical devices?
Do you have a history of fainting in association with needles?
Do you have a history of diabetes?
Please add any additional information here related to any of the questions above.
Name
(pounds)
(feet, inches)
Sex:
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