First Name:

Last Name:

Middle Name:

Date of Birth:

Gender:
Male Female
Email:

Pain Scale

Please Indicate, on the pain scale below, your average pain for your problem area based on the last month on a scale from 0-10.

0=No Pain   10=Highest Level of Pain

0   1   2   3   4   5   6   7   8   9   10  

How long has it been since your Regenerative Cellular Procedure?

Initial Procedure   3 months   6 months   12 months   24 months  

Would you have this procedure done again?

Yes No Maybe

Compared to your condition prior to the procedure, what percent difference have you seen in your condition? (from -100% worse to 100% better; 0%= no change)

%

Would you recommend this procedure to someone else?

Yes No Maybe

Have you experienced any complications you believe are due to the procedure?

Yes No Maybe

If yes, please explain
ASES Shoulder Score    
 
1. Usual Work   2. Usual Sport/Leisure activity?
 

 
3. Do you have shoulder pain at night?   4) Do you take pain killers such as paracetamol (acetaminophen), diclofenac, or ibuprofen?
Yes   Yes
No   No
     
5) Do you take strong pain killers such as codeine, tramadol, or morphine?   6) How many pills do you take on an average day?
Yes  
No  

 
7) Intensity of pain?
10 9 8 7 6 5 4 3 2 1 0
Pain as bad as it can be
No pain at all
     
8) Is it difficult for you to put on a coat?   9) Is it difficult for you to sleep on the affected side?
Unable to do   Unable to do
Very difficult to do   Very difficult to do
Somewhat difficult   Somewhat difficult
Not difficult   Not difficult

 
10) Is it difficult for you to wash your back/do up bra?   11) Is it difficult for you manage toiletting?
Unable to do   Unable to do
Very difficult to do   Very difficult to do
Somewhat difficult   Somewhat difficult
Not difficult   Not difficult

 
12) Is it difficult for you to comb your hair?   13) Is it difficult for you to reach a high shelf?
Unable to do   Unable to do
Very difficult to do   Very difficult to do
Somewhat difficult   Somewhat difficult
Not difficult   Not difficult

 
14) Is it difficult for you to lift 10lbs. (4.5kg) above your shoulder?   15) Is it difficult for you to throw a ball overhand?
Unable to do   Unable to do
Very difficult to do   Very difficult to do
Somewhat difficult   Somewhat difficult
Not difficult   Not difficult

 
16) Is it difficult for you to do your usual work?   17) Is it difficult for you to do your usual sport/leisure activity?
Unable to do   Unable to do
Very difficult to do   Very difficult to do
Somewhat difficult   Somewhat difficult
Not difficult   Not difficult

 
The Total ASES score is:
 
Reference : American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness.Michener LA, McClure PW, Sennett BJ.J Shoulder Elbow Surg. 2002 Nov-Dec;11(6):587-94.