The Japanese Orthopaedic Association Shoulder 36 V 1.3Shoulder Evaluation Sheet20//Name () Age
Please use the space provided
and use a circle ( ) to mark the answer.
Please indicate your gender
Male FemaleRight )Please indicate your dominant hand ( Left
Please indicate your shoulder/s affected
Left
Rightor Both .
If both shoulders are affected, please fill in a questionnaire for each of your shoulders. Please
Left
Right
indicate a shoulder that you will provide answers for this questionnaire
Diagnosis
A total of thirty-six questions are provided to evaluate your affected shoulders. Please avoid
answering these questions in the presence of a doctor or medical personnel nearby.
Answer these questions by choosing level of difficulty from 0-4 shown below:
I have no difficulties
I have minor difficulties
I have some difficulties but I can manage on my own
I have major difficulties and require help from someone
I cannot do it (at all)Please circle to choose level of difficulty in the space (question.

Example:) provided on the right side of each

( 0,1,2 ,3,4 )If you come across such situations or activities that you may not have done before, please try to
imagine the situation and choose level of difficulty you are most comfortable with. If a question
is not clear to you, you may leave it unanswered and move on to complete the questionnaire.
An unanswered question may be reviewed with your doctor (or person in charge) afterwards.
Answer
1. Daily activities at home

(0,1,2,3,4)

2. Reading a newspaper at a shoulder high(0,1,2,3,4)

3. Reaching a back pocket of your trousers using your affected side(0,1,2,3,4)

4. Putting your arm through a jacket(0,1,2,3,4)

5. Wearing a sweater jacket over your head

(0,1,2,3,4)

The Japanese Orthopaedic Association Shoulder 36 V 1.3
6.

Taking off clothes(0,1,2,3,4)

7.

Placing a jacket on a hanger(0,1,2,3,4)

8.

Knotting your hands together behind your head

(0,1,2,3,4)

9.

Washing your face with hands(0,1,2,3,4)(0,1,2,3,4)

10. Combing your hair

11. Washing your armpit opposite to your affected shoulder, using your affected shoulder

12. Rinsing your whole body by holding a shower head with your affected side

(0,1,2,3,4)(0,1,2,3,4)

13. Washing your back with a towel by holding both ends of the towel with an affected side holding the topof the towel(0,1,2,3,4)

14. Squeezing out the water from a towel using both hands(0,1,2,3,4)

15. Carrying a bowl of soup on the tray

(0,1,2,3,4)

16. Reaching into a condiment on a table (soy sauce, salt, pepper, etc.) using your affected shoulder(0,1,2,3,4)

17. Eating(0,1,2,3,4)

18. Tying an apron behind your back(0,1,2,3,4)

19. Washing plates with a sponge(0,1,2,3,4)

20. Placing plates on a shelf above your head height using the affected shoulder (0,1,2,3,4)

21. Holding a filled up kettle with your affected side(0,1,2,3,4)

22. Clapping your hands 10 times(0,1,2,3,4)

23. Stretching your body with your hands held up(0,1,2,3,4)

24. Sleeping side ways with your affected shoulder lying on the floor(0,1,2,3,4)

25. Getting a good sleep(0,1,2,3,4)

26. Feeling less fatigue than usual getting through the week(0,1,2,3,4)

27. Keeping both your arms horizontal for a minute(0,1,2,3,4)

28. Walking with your arms swinging back and forth(0,1,2,3,4)

The Japanese Orthopaedic Association Shoulder 36 V 1.3
29. Managing daily tasks using your affected shoulder, without help of another shoulder(0,1,2,3,4)

30. Wiping windows with your affected shoulder at a head high(0,1,2,3,4)

31. Going shopping close to your house(0,1,2,3,4)

32. Opening an umbrella (with exception to Push-Button umbrella) with your affected shoulder(0,1,2,3,4)

33. Getting on a bus or train(0,1,2,3,4)

34. Holding on a strap in a bus or train with your affected shoulder(0,1,2,3,4)

35. Moving your shoulders at a recreational level of activities(0,1,2,3,4)

36. Moving your shoulders at a competitive level of activities(0,1,2,3,4)

Official use onlyResults
DomainPain

ROMPowerGeneral Health

ADL

Ability for Sports

Score.

Changing the content of the assessment criteria without permission is strictly prohibited.

The Japanese Orthopaedic Association
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