The Penn Shoulder Score: Functional Subscale Form

Please fill out the new patient paperwork online and submit to our office prior to your first visit.

 

Due to COVID-19, we want to minimize patient time spent in the waiting area.  We pride ourselves on maximizing your time with your physical therapist to work one on one and begin the process of recovery.  Paperwork is an unfortunate necessity of the process but we want to minimize this burden and have it done prior to your visit so that we can get your treatment started!

FORM - The Penn Shoulder Score: Functional Subscale

Reach the small of your back to tuck in your shirt with your hand

Wash the middle of your back/hook bra

Perform necessary toileting activities

Wash the back of opposite shoulder

Comb hair

Place hand behind head with elbow held straight out to the side

Dress self (including put on the coat and pull shirt off overhead)

Sleep on affected side

Open a door with affected arm

Carry a bag of groceries with affected arm

Carry a briefcase/small suitcase with affected arm

Place a soup can (1-2lb) on a shelf at shoulder level without bending your elbow

Place a one gallon container (8-10lb) on a shelf at shoulder level without bending elbow

Reach a shelf above your head without bending your elbow

Place soup can (1-2lb) on a shelf overhead without bending your elbow

Place a one gallon container (8-10lb) on a shelf overhead without bending your elbow

Perform usual sport/hobby

Perform household chores (cleaning, laundry, cooking)

Throw overhand/swim/overhead racquet sports (circle all that apply to you)

Work full-time at your regular job

4 + 9 =

Our front office person administrator will inform you of the proper functional outcome to fill out and submit as well.  Your therapist will score this and establish a baseline of how you currently rate your symptoms.

If you need to contact Dr. Damon Daura, the email is: Damon@DamonPT.com

For any questions – please reach out! 
Totowa 973-237-1975   |   Lafayette Township 973-862-6377