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