Frozen Shoulder Questionnaire

Take a self test to determine if you have the many influences that cause the symptoms of  a frozen shoulder? Please indicate by selecting from one of the following: 0 = none, 1 = occasionally, 2 = mild symptoms, 3 = moderate symptoms, 4 = severe, and 5 = debilitating

0 1 2 3 4 5    1.  Unable to lift your arm above the level of your shoulder?

0 1 2 3 4 5    2.  Can't move your arm backward or forward without pain?

0 1 2 3 4 5    3.  Do you have pain or tingling in the arm and hands?

0 1 2 3 4 5    4.  Do you have chest pains the same time you move your arm or
              shoulder?

0 1 2 3 4 5    5.  Are the muscles in your chest tight or in spasm?

0 1 2 3 4 5    6.  Does you jaw pop or have pain?

0 1 2 3 4 5    7.  Do you have neck pain?

0 1 2 3 4 5    8.  Do you have headaches?

0 1 2 3 4 5    9.  Are your hands stiff and swollen in the morning?   

0 1 2 3 4 5   10. Can't bend the arm behind the back without pain?

0 1 2 3 4 5   11. Did you have a blow trauma to your chest like a seat belt or steering
              wheel, or weight lifting?

0 1 2 3 4 5   12. Have you been to the dentist where your mouth was open for more
              than  15 minutes?

0 1 2 3 4 5   13. Do you work on a computer for more than two hours straight? 

0 1 2 3 4 5   14. Have you lifted heavy object of more than fifty pounds and twisted
              while lifting? 

0 1 2 3 4 5   15. Have you had a heavy object fall on your head and shoulder?

0 1 2 3 4 5   16. Have you been thrown off while riding a horse?

0 1 2 3 4 5   17. Have you dived into a pool from over ten feet and done a belly
              smacker on your chest?

0 1 2 3 4 5   18. Have you taken a fall while water skiing?

0 1 2 3 4 5   19. Have you taken a fall while snow skiing?

0 1 2 3 4 5   20. Have you been injured while playing a sport: basketball, football,
              hockey, soccer, volleyball.

0 1 2 3 4 5   21. Have you been water wrestling with someone perched on your
             shoulders and they fell forward wrenching your neck?

0 1 2 3 4 5   22. Have you been arm wrestling?

0 1 2 3 4 5   23. Have you been in car accidents where your chest or head hit the
             steering wheel?

0 1 2 3 4 5   24. Have you been in a car accident with your head hit the dash or
             windshield?

0 1 2 3 4 5   25. Do you eat microwave food?

0 1 2 3 4 5   26. Do you eat foods that have Equal, Nutrasweet, Aspartame or 
             Splenda in the ingredients?

0 1 2 3 4 5   27. Do you eat foods with MSG in the ingredients?

0 1 2 3 4 5   28. Do you have high blood pressure?

0 1 2 3 4 5   29. Have you been exposed to toxic materials like, mercury, lead,
             arsenic, nickel, copper, cadmium, tin, 

0 1 2 3 4 5   30. Have you been exposed to toxic chemicals?

0 1 2 3 4 5   31. have you been exposed to film developer for long periods of time.

0 1 2 3 4 5   32. Have you been exposed to petroleum products for a long time?

0 1 2 3 4 5   33. Have you broken your arm, wrist, or dislocated a shoulder?

0 1 2 3 4 5   34. Have you twisted your rib cage in a fall?

0 1 2 3 4 5   35. Are your collar bones of equal height?

0 1 2 3 4 5   36. Are you flat footed?

0 1 2 3 4 5   37. Do your feet hurt a lot?

0 1 2 3 4 5   38. Have you ever broken a hip, knee or ankle?

0 1 2 3 4 5   39. Have you ever been diagnosed with carpal tunnel syndrome?

0 1 2 3 4 5   40. Have you ever been diagnosed with tendonitis of your elbow?

If you answer "YES" to more than ten questions, you have tendencies toward  shoulder trauma, which links to other systems in the body creating a network of deeper layers and causes. These causes link to prior injuries, poor digestive patterns, cranial injuries, spinal injuries, hidden disc's injuries in the neck and upper back,  glandular disturbances,  and early primitive reflexes from early childhood, embryonic reflexes before birth. All this says you have learned some very bad posture habits trauma induced and movements that continue to aggravate your  shoulder.   

 After taking the test above, send the results to us with the information below. We'll get back to you by E-mail within a week. We will give you an overview and a new perspective of what can be done. Or you can call our office for an appointment and consultation. 706-379-1225

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