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Plexus Physical Therapy - Status Questionnaires

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 estimate
of 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.

Name
Your answer
Date
MM
/
DD
/
YYYY
Open a tight or new jar
Do heavy household chores (e.g. wash walls, floors)
Carry a shopping bag or briefcase
Wash your back
Use a knife to cut food
Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g. golf, hammering, tennis, etc)
During the past week, to what extent has your arm, shoulder or hand problem interfered with you normal social activities with my friend, 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?
Please rate the severity of arm, shoulder or hand pain
Please rate the severity of tingling 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?
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