QuickDash – Optimal Physical Therapy

QuickDash Form

First Name

Last Name

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.

Open a tight or new jar. No Difficulty Mild Difficulty Moderate Difficulty Severe Difficulty Unable 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 hang (e.g. golf, hammering, tennis, etc.).

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?

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 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.

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

Have Questions?

We would love to start you on your path to wellness today.

Optimal Physical Therapy

Phone: 307.333.2873

Fax: 307.333.4034

Address: 4120 South Poplar Street Casper, WY 82601

Optimal Pediatric Therapy

Phone: 307.333.6200

Fax: 307.333.5880

Address: 4270 South Poplar Casper, WY 82601

Optimal Speech and Language

Phone: 307.333.2873

Fax: 307.333.4034

Address: 4120 South Poplar Street Casper, WY 82601