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FAQs
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Home
Services
Physical Therapy
Pediatric Therapy
FAQs
Contact Us
QuickDash Form
First Name
Last Name
Please rate your pain level with activity: (No Pain = 0, Very Severe Pain = 10)
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Please rate your Worst Pain level: (No Pain = 0, Very Severe Pain = 10)
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10
Please rate your Current Pain level: (No Pain = 0, Very Severe Pain = 10)
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Please rate your Best Pain level: (No Pain = 0, Very Severe Pain = 10)
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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 selecting the appropriate number. If you did not have the opportunity to 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 selecting the number below the appropriate response:
Open a tight or new jar.
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
Open a tight or new jar. No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable Do heavy household chores (e.g. wash walls, floors).
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
Carry a shopping bag or briefcase.
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
Wash your back.
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
Use a knife to cut food.
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
Recreational activities in which you take some force or impact through your arm, shoulder or hang (e.g. golf, hammering, tennis, etc.).
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
Please rate your ability to do the following activities in the last week by selecting the number below the appropriate response:
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?
Not at all
Slightly
Moderately
Quite A Bit
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?
Not Limited At All
Slightly Limited
Moderately Limited
Very Limited
Unable
Please rate your ability to do the following activities in the last week by selecting the number below the appropriate response:
Please rate the severity of the following symptoms in the last week.
None
Mild
Moderate
Severe
Extreme
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?
None
Mild Difficulty
Moderate Difficulty
Severe Difficulty
So Much Difficulty That I Cant Sleep
Submit
