Rose Institute for Joint Replacement

Patient Survey - Shoulder

Please take a few minutes to fill out the following form. Your response will be sent to our Institute and someone will contact you shortly.

Name
Email
Tel #
Do you have pain in your shoulder?		Yes No
Does your shoulder pain inhibit your ability to participate in the activities you enjoy?		Yes No
Does your shoulder pain wake you from sleep at night?		Yes No
Do you have a constant ache in your shoulder?		Yes No
Does over-the-counter medication, such as Tylenol, Aleve or Advil bring relief to the pain?		Yes No
Have you had any past treatments for your shoulder pain that were unsuccessful?		Yes No