Frank R. yes, MD Health Status Questionnaire Patient Name Today s Date Dear Patient, As your partner in health management, we are most interested in understanding your overall health status and the impact of our management on it. The questions below are from a standardized health status questionnaire that has been shown to be most helpful in health management. Please take time to complete each of these questions as accurately as you can. Thank you. The Staff at Instructions: this survey asks for your views about your health. This information will be summarized in your medical record and will help us keep track of how you feel and how well you are able to do your usual activities. Answer every question by checking the appropriate box. If you are unsure about how to answer a question, please give the best answer you can. In general, would you say your health is: o Excellent o Very Good o Good o Fair o Poor Compared to one year ago, how would you rate your health in general now? o Much better now than one year ago o Somewhat better now than one year ago o About the same as one year ago o Much worse than one year ago o Somewhat worse than one year ago The following questions are about activities you might do during a typical day. Does your health limit you in these activities? If so, how much? (only check one box per line) Activities:, limited, limited, not a lot a little limited at all Vigorous activities such as running, lifting heavy objects, participating in o o o strenuous sports Moderate activities such as moving a table, pushing a vacuum o o o cleaner, bowling,or playing golf Lifting or carrying groceries o o o Climbing several flights of stairs o o o Climbing one flight of stairs o o o Bending, kneeling, or stooping o o o Walking more than a mile o o o Walking several blocks o o o Walking one block o o o Bathing and dressing yourself o o o 9311 - Rd
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (only check one box per line) Cut down the amount of time you spent on work or other activities o o Accomplished less than you would like o o Were limited to the kind of work or other activities o o Had difficulty performing the work or other activities (for example, it took extra effort) o o During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? (only check one box per line) Cut down on the amount of time you spent on work or other activities o o Accomplished less than you would like o o Didn t do work or other activities as carefully as usual o o During the past 4 weeks, to what extent have your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? o t at all o Slightly o Moderately o Quite a bit o Extremely How much bodily pain have you had during the past 4 weeks? o ne o Very mild o Mild o Moderate o Severe o Very severe During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? o t at all o A little bit o Moderately o Quite a bit o Extremely These questions are about how you feel and how things have been with you during the past month. For each question, please give the one answer that comes closest to the way you have been feeling. (only check one box per line) How much of the time during the past month All of the Most of A good bit Some of A little of ne of time the time of the time the time the time the time Did you feel full of pep? o o o o o o Have you been a very nervous person? o o o o o o Have you felt so down in the dumps that nothing o o o o o o could cheer you up? Have you felt calm and peaceful? o o o o o o Did you have a lot of energy? o o o o o o Have you felt downhearted and blue? o o o o o o Did you feel worn out? o o o o o o Have you been a happy person? o o o o o o Did you feel tired? o o o o o o Has your health limited your social activities (like o o o o o o visiting with friends or close relatives)?
Please choose the answer that best describes how true or false each of the following statements is for you. (only check one box per line) Definitely Mostly Don t Mostly Definitely true true know false false I seem to get sick a little easier than other people o o o o o I am as healthy as anybody I know o o o o o I expect my health to get worse o o o o o My health is excellent o o o o o Please answer yes or no for each question: In the past year, have you had two weeks or more during which you felt sad, blue, or depressed; o o or when you lost all interest or pleasure in things that you usually care about or enjoyed? Have you had two years or more in your life when you felt depressed or sad most days, o o even if you felt ok sometimes? Have you felt depressed or sad much of the time in the past year? o o Comments:
Frank R. yes, MD Shoulder Pain/Function/Stability Patient Name Today s Date Pain (place an X on the line to describe pain): 0 1 2 3 4 5 6 7 8 9 10 pain Worst possible pain Function (circle one): 0 2 3 4 5 t satisfactory Somewhat satisfactory Function satisfactory Stability: Does your shoulder feel unstable (as if it s going to dislocate)? o o How unstable is your shoulder (place an X on the line): 0 1 2 3 4 5 6 7 8 9 10 Very Stable Very Unstable Function (check one): o Unable to use shoulder o Only light activities possible o Able to do light housework or most daily activities of living o Most housework, shopping, driving, able to do hair, and dress/undress including fastening brassiere o Slight restrictions only o rmal activities Circle the number that indicates your ability to do the following activities with your painful shoulder: 0 = Unable to do 1 = Very difficult to do 2 = Somewhat able to do 3 = t difficult to do 4 = Have not tried 1. Put on a coat 0 1 2 3 4 6. Reach a high shelf 0 1 2 3 4 2. Sleep on your painful side 0 1 2 3 4 7. Lift 10 pounds over shoulder 0 1 2 3 4 3. Reach up behind back 0 1 2 3 4 8. Throw ball overhead 0 1 2 3 4 4. Manage toileting 0 1 2 3 4 9. Do usual work 0 1 2 3 4 5. Comb hair 0 1 2 3 4 10. Do usual sport 0 1 2 3 4 Pain (mark an X beside one of the following): Pain all of the time and unbearable; strong medication frequently needed Pain all of the time but bearable; strong medication used occasionally Little or no pain at rest; pain present during light activities; anti-inflammatories frequently used Pain during heavy or particular activities only; anti-inflammatories used occasionally Occasional and slight ne 9311 - Rd F 12Rev. 3/04
Frank R. yes, MD Simple Shoulder Test Patient Name Today s Date Dominant hand (check one): o Right o Left o Ambidextrous Shoulder evaluated (check one): o Right o Left 1. Is your shoulder comfortable with your arm at rest by your side? o o 2. Does your shoulder allow you to sleep comfortably? o o 3. Can you reach the small of your back to tuck in your shirt with your hand? o o 4. Can you place your hand behind your head with the elbow straight out to the side? o o 5. Can you place a coin on a shelf at the level of your shoulder without bending your elbow? o o 6. Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow? o o 7. Can you lift eight pounds (a full gallon container) to the level of your shoulder without bending your elbow? o o 8. Can you carry twenty pounds at your side with the affected extremity? o o 9. Do you think you can toss a softball underhand twenty yards with the affected extremity? o o 10. Do you think you can toss a softball overhand twenty yards with the affected extremity? o o 11. Can you wash the back of your opposite shoulder with the affected extremity? o o 12. Would your shoulder allow you to work full-time at your regular job? o o Office Use Only: o DJD o SDJD o RA o FS o PTSS o AVN o CA o CTA o SA o PTCL o RCT o TUBS o AMBRII 9311 - Rd F13 Rev. 3/04