Please complete the following questionnaire to help us track your progress and identify how to best help you!
This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer every question, based on your condition in the last week, by circling the appropriate number.
If you did not have the opportunityto perform an activity in the past week, please make your best estimateof which response would be the most accurate.
It doesn’t matter which hand or arm you use to perform the activity; please answer based on your ability regardless of how you perform the task.
Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.