Srq

ATTACHMENT G2: Shoulder Rating Questionnaire (SRQ) Instrument

Form Approved

OMB No. 0920-0964

Exp. Date xx-xx-xxxx

Please answer the following questions regarding the shoulder for which you have been evaluated or treated. If a question does not apply to you, leave that question blank. If you indicated that both shoulders have been evaluated or treated, please complete a separate questionnaire for each shoulder and mark the corresponding side (right or left) at the top of each form.

1. Considering all the ways that your shoulder affects you, circle a number on the scale below for how well you are

doing.

Very poorly >

0

1

2

3

4

5

6

7

8

9

10

< Very well

The following questions refer to pain.

2. During the past month, how would you describe the usual pain in your shoulder at rest?

(A) Very severe

(B) Severe

(C) Moderate

(D) Mild

(E) None

3. During the past month, how would you describe the usual pain in your shoulder during activities?

(A) Very severe

(B) Severe

(C) Moderate

(D) Mild

(E) None

4. During the past month, how often did the pain in your shoulder make it difficult for you to sleep at night?

(A) Every day

(B) Several days per week

(C) One day per week

(D) Less than one day per week

(E) Never

5. During the past month, how often have you had severe pain in your shoulder?

(A) Every day

(B) Several days per week

(C) One day per week

(D) Less than one day per week

(E) Never

Public reporting burden of this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0964).

The following questions refer to daily activities.

6. Considering all the ways you use your shoulder during daily personal and household activities (i.e. dressing, washing, driving,

household chores, etc), how would you describe your ability to use your shoulder?

(A) Very severe limitation; unable

(B) Severe limitation

(C) Moderate limitation

(D) Mild limitation

(E) No limitation

Questions 7–11: During the past month, how much difficulty have you had in each of the following activities due to your shoulder?

7. Putting on or removing a pullover, sweater or shirt:

(A) Unable

(B) Severe difficulty

(C) Moderate difficulty

(D) Mild difficulty

(E) No difficulty

8. Combing or brushing your hair.

(A) Unable

(B) Severe difficulty

(C) Moderate difficulty

(D) Mild difficulty

(E) No difficulty

9. Reaching shelves that are above your head.

(A) Unable

(B) Severe difficulty

(C) Moderate difficulty

(D) Mild difficulty

(E) No difficulty

10. Scratching or washing your lower back with your hand.

(A) Unable

(B) Severe difficulty

(C) Moderate difficulty

(D) Mild difficulty

(E) No difficulty

11. Lifting or carrying a full bag of groceries (8–10 pounds).

(A) Unable

(B) Severe difficulty

(C) Moderate difficulty

(D) Mild difficulty

(E) No difficulty

The following questions refer to recreational or athletic activities.

12. Considering all the ways you use your shoulder during recreational or athletic activities (i.e. baseball, golf, aerobics, gardening, etc), how would you describe the function of your shoulder?

(A) Very severe limitation; unable

(B) Severe limitation

(C) Moderate limitation

(D) Mild limitation

(E) No limitation

13. During the past month, how much difficulty have you had throwing a ball overhand or serving in tennis due to your shoulder?

(A) Unable

(B) Severe difficulty

(C) Moderate difficulty

(D) Mild difficulty

(E) No difficulty

14. List one activity (recreational or athletic) that you particularly enjoy and then select the degree of limitation you have, if any, due to your shoulder.

Activity ______________________________

(A) Unable

(B) Severe limitation

(C) Moderate limitation

(D) Mild limitation

(E) No limitation

The following questions refer to work.

15. During the past month, what has been your main form of work?

(A) Paid work (list type of work) ________________________________

(B) Housework

(C) Schoolwork

(D) Unemployed

(E) Disabled due to your shoulder

(F) Disabled secondary to other causes

(G) Retired

If you answered D, E, F, or G to the above question, please skip questions 16–19 and go on to question 20.

16. During the past month, how often were you unable to do any of your usual work because of your shoulder?

(A) All days

(B) Several days per week

(C) One day per week

(D) Less than one day per week

(E) Never

17. During the past month, on the days that you did work, how often were you unable to do your work as carefully or as efficiently as you would like because of your shoulder?

(A) All days

(B) Several days per week

(C) One day per week

(D) Less than one day per week

(E) Never

18. During the past month, on the days that you did work, how often did you have to work a shorter day because of your

shoulder?

(A) All days

(B) Several days per week

(C) One day per week

(D) Less than one day per week

(E) Never

19. During the past month, on the days that you did work, how often did you have to change the way that your usual

work is done because of your shoulder?

(A) All days

(B) Several days per week

(C) One day per week

(D) Less than one day per week

(E) Never

The following questions refer to satisfaction and areas for improvement.

20. During the past month, how would you rate your overall degree of satisfaction with your shoulder?

(A) Poor

(B) Fair

(C) Good

(D) Very good

(E) Excellent

21. Please rank the two areas in which you would most like to see improvement (place a 1 for the most important, a 2 for the

second most important).

Pain _____

Daily personal and household activities _____

Recreational or athletic activities _____

Work _____

Thank you for your cooperation.

Scoring:

Maximum score is 100. Weightings are as follows. Maximum score of 15 pts for global assessment (domain score multiplied by 1.5). Maximum score of 40 points for pain (domain score multiplied by 4). Maximum score of 20 points for daily activities (domain score multiplied by 2). Maximum score of 15 pts for recreational and athletic activities (domain score multiplied by 1.5). Maximum score of 10 pts for work (domain score multiplied by 1).

Domains are as follows:

Global assessment (Q1)

Pain (Q2-Q5)

Daily Activities (Q6-Q11)

Recreational and Athletic Activities (Q12-Q14)

Work (Q15-Q19)

Satisfaction and Importance (Q20 and Q21) are unscored domains.

The global assessment domain score is the Q1 rating score. Other domain scores are calculated by averaging the scores of individual completed questions and multiplying by two. Individual questions are scored by assigning points to the multiple choice options as, A = 1, B = 2, C = 3, D = 4, E = 5.