Pain Intensity (45 points)

None

Mild

Moderate

Severe

45 pts

30 pts

15 pts

0 point

Motion (20 points): Arc of motion

Arc of motion greater than 100˚

Arc between 50˚ to 100˚

Arc less than 50˚

20 pts

15 pts

5 points

Stability (10 points)

Stable Moderate stability

Grossly unstable

10 pts

5 pts

0 points

Function (tick as many as able) (25 pts)

Can comb hair

Can eat

Can perform hygiene

Can don shirt

Can don shoe

5 pts

5 pts

5 pts

5 pts

5 points

Total Score

Excellent

Good

Fair

Poor

90 - 100 pts

75 - 89 pts

60 - 74 pts

0 - 59 pts