Name:
姓名:

Contact Number:
联络号码:

Email:
电邮:

1) How much difficulty do you have?
您目前是否面对以下所描述的困难？

Choose the number that best describes your experience where: 0= no difficulty and 10=so difficult that it requires help.
请圈出最符合您情况的数字：0 = 无困难， 10 = 非常困难并需要帮助

Washing your hair
洗头

Washing your back
洗背

Wearing a T-shirt
穿T-恤

Wearing buttoned clothes
穿扣子的衣服

Wearing a pants
穿裤子

Placing objects on high shelf
将物品放在高架上

Carrying heavy object (above 4.5kg)
拿重物 (4.5公斤以上）

Removing something from back pocket / wearing bra (for women)
从后袋中取出东西 / 穿胸罩 (女性）

Total disability score: / 80 x 100% = % (Note: If a person does not answer all questions divide by the total possible score, eg. if 1 question missed divide by 70)
失能的总分：_____ / 80 x 100% (备注：若回答者未能完成所有的问题，那分母将有所改变。举例说明：若未能回答其中一道题那就得除以70，如此类推）

2) Does the pain move down your arm or up your neck?
疼痛是否蔓延上至脖子或下至手臂？
Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直

3) Have you dropped items due to your condition?
您是否因疼痛的出现导致手臂无力，甚至持物会掉落？
Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直

4) Do you feel that your affected shoulder / arm is weaker?
您是否觉得受影响的肩膀或手臂较软弱？
Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直

Thank you for completing this questionnaire to let us better understand your pain.
感谢您回答此疼痛问卷，让我们更了解您的疼痛状况。

We respect and keep your data safe.
我们尊重并保证您的个人资料安全。

In accordance with the Personal Data Protection Act (PDPA) of Singapore,
根据新加坡个人资料保护法 （PDPA), *

I consent to the sharing of my medical records within Singapore Paincare Center as well as other healthcare providers for any investigations, treatments and other healthcare purposes if necessary. (E.g. Hospitals, Imaging Centers, Physiotherapy Centers, etc.)我同意与新加坡疼痛护理中心以及其他医疗保健提供者共享我的医疗记录，以便在必要时进行任何检查，治疗或用于其他医疗保健的目的。(例如：医院，扫描中心，物理治疗中心等 Please refer to our privacy policy: https://www.paincarecenter.com.sg/privacy-statement.

I consent to receive marketing updates and educational information from Singapore Paincare Center.我同意接收新加坡疼痛护理中心的营销材料，包括相关活动的更新动态和教育信息

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