Upper Extremity (Shoulder, Elbow, Hand) Assessment
Full Name
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First Name
Last Name
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Month
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Day
Year
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1. Open a tight or new jar.
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1. No Difficulty
2. Mild Difficulty
3. Moderate Difficulty
4. Severe Difficulty
5. Unable
2. Do Heavy Household Chores (eg wash wall, floors).
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1. No Difficulty
2. Mild Difficulty
3. Moderate Difficulty
4. Severe Difficulty
5. Unable
3. Carry a shopping bag or briefcase.
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1. No Difficulty
2. Mild Difficulty
3. Moderate Difficulty
4. Severe Difficulty
5. Unable
4. Wash your back.
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1. No Difficulty
2. Mild Difficulty
3. Moderate Difficulty
4. Severe Difficulty
5. Unable
5. Use a knife to cut food
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1. No Difficulty
2. Mild Difficulty
3. Moderate Difficulty
4. Severe Difficulty
5. Unable
6. Recreational activities in which you take some force or impact through your arm, shoulder, or hand.
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1. No Difficulty
2. Mild Difficulty
3. Moderate Difficulty
4. Severe Difficulty
5. Unable
7. 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.
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1. Not at all
2. Slightly
3. Moderately
4. Quite a bit
5. Extremely
8. 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.
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1. Not limited at all
2. Slightly limited
3. Moderately limited
4. Very limited
5. Unable
Please rate the severity of the following symptoms in the last week. (Check One).
9. Arm, Shoulder, or hand pain
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1. None
2. Mild
3. Moderate
4. Severe
5. Extreme
10. Tingling (pins and needles) in your arm, shoulder or hand.
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1. None
2. Mild
3. Moderate
4. Severe
5. Extreme
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? (Circle Number).
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1. No Difficulty
2. Mild Difficulty
3. Moderate Difficulty
4. Severe Difficulty
5. So Much Difficulty That I Can't Sleep.
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