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QuickDASH - Functional Assessment of Upper Extremity
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 option. 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 most accurate.
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Name
*
First
Last
Please rate your ability to do the following activities in the last week by choosing the appropriate response in the dropdown menu
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 hand ( e.g. golf, hammering, tennis, etc.)
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
Over 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 At All
Slightly
Moderately
Quite A Bit
Extremely
Please rate the severity of the following symptoms in the last week
Arm, shoulder, or hand pain
None
Mild
Moderate
Severe
Extreme
Please rate the severity of the following symptoms in the last week
Tingling (pins and needles) in your arm, shoulder or hand
None
Mild
Moderate
Severe
Extreme
During the past week, how much difficulty have you had sleeping because of pain in your arm, shoulder, or hand?
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
So Much Difficulty Than I Can't Sleep
Submit
