Disabilities of the Arm, Shoulder and Hand

This form helps us understand how your upper limb condition is affecting your life. Please answer as honestly as possible. Please rate your ability to do the following activities in the last week. (If you haven't done an activity, please answer based on how difficult do you think it would be.)

Name *

Activities *

(1) No difficulty

(2) Mild difficulty

(3) Moderate difficulty

(4) Severe difficulty

(5) Unable

Open a tight or new jar

Write

Turn a key

Prepare a meal

Push open a heavy door

Place an object on a shelf above your head

Do heavy household chores (e.g., wash walls, wash floors)

Garden or do yard work

Make a bed

Carry a shopping bag or briefcase

Carry a heavy object (over 10 lbs)

Change a lightbulb overhead

Wash or blow dry your hair

Wash your back

Put on a pullover sweater

Use a knife to cut food

Recreational activities which require little effort (e.g., cardplaying, knitting, etc.)

Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.)

Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.)

Manage transportation needs (getting from one place to another)

Sexual activities

(1) No difficulty

(2) Mild difficulty

(3) Moderate difficulty

(4) Severe difficulty

(5) Unable

Open a tight or new jar

Write

Turn a key

Prepare a meal

Push open a heavy door

Place an object on a shelf above your head

Do heavy household chores (e.g., wash walls, wash floors)

Garden or do yard work

Make a bed

Carry a shopping bag or briefcase

Carry a heavy object (over 10 lbs)

Change a lightbulb overhead

Wash or blow dry your hair

Wash your back

Put on a pullover sweater

Use a knife to cut food

Recreational activities which require little effort (e.g., cardplaying, knitting, etc.)

Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.)

Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.)

Manage transportation needs (getting from one place to another)

Sexual activities

During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbors or groups? *

(1) Not at all

(2) Slightly

(3) Moderately

(4) Quite a bit

(5) Extremely

During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem? *

(1) Not limited at all

(2) Slightly limited

(3) Moderately limited

(4) Very limited

(5) Unable

Symptoms *

(1) None

(2) Mild

(3) Moderate

(4) Severe

(5) Extreme

Arm, shoulder or hand pain

Arm, shoulder or hand pain when you performed any specific activity

Tingling (pins and needles) in your arm, shoulder or hand

Weakness in your arm, shoulder or hand

Stiffness in your arm, shoulder or hand

During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? *

(1) No difficulty

(2) Mild difficulty

(3) Moderate difficulty

(4) Severe difficulty

(5) So much difficulty that I can't sleep

I feel less capable, less confident or less useful because of my arm, shoulder or hand problem *

(1) Strongly disagree

(2) Disagree

(3) Neither agree nor disagree

(4) Agree

(5) Strong agree

Submit

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms