PASC Stem Cell-pRCT Shoulder Scores (SANE/ASES)
Please enter the date *
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Last Name *
Your answer
First Name *
Your answer
Date of Birth *
MM
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DD
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YYYY
Treating Doctor *
Which shoulder was treated? *
If both shoulders were treated please fill out a separate survey for each shoulder
Shoulder SANE-F Score *
Enter a number for the current functional level of your shoulder. 100% is normal function, 0% is completely disabled
Your answer
Shoulder SANE-I Score (% improvement)
Enter a number for the % improvement in your shoulder compared to before treatment. 100% is completely better; 0% is no improvement
Your answer
The ASES Shoulder Survey should take 10 minutes to fill out.
Your answer
Are you right or left handed?
What is your work?
Your answer
What is your favorite sports or leisure activity?
Your answer
If your shoulder is unstable, please describe how often you feel the instability or how often it dislocates. Please leave blank if you have no shoulder instability.
Your answer
Over the last week, what is the intensity of your shoulder pain?
no pain
extreme pain
Is it difficult for you to put on a coat?
Is it difficult for you to sleep on the affected side?
Is it difficult for you to wash your back or put on a bra?
Is it difficult for you to managing toiletting?
Is it difficult for you to comb your hair?
Is it difficult for you to reach a high shelf?
Is it difficult for you to lift 10 pounds overhead?
Is it difficult for you to throw a ball overhand?
Is it difficult for you to do your usual work?
Is it difficult for you to do your usual sports or leisure activity?
ASES Shoulder Score (PASC Staff Use)
1. VAS score (times) 5 = X 2. 1.67 (times) ADL cumulative score = Y 3. ASES Score = X+Y (max is 100)
Your answer
Thank you for completing the ASES Shoulder Survey!
Your answer
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