• Elbow/wrist/hand

  • The questions below will help us understand the amount of difficulty you have had with your arm in the past week. You will be describing your average arm symptoms over the past week on a scale 0-10. Please provide an answer for all questions. If you did not perform an activity because of pain or because you were unable ,then you should circle a “10”. If you are unsure please estimate to the best of your ability. Only leave items blank if you never perform that activity. Please indicate this by drawing a line completely through the question.

  • PAIN in your affected arm

    Rate the average amount of pain in your arm over the past week by circling the number that best describes your pain on a scale from 0-10. A zero (0) means that you did not have any pain and a ten (10) means that you had the worst pain imaginable.
  • Pain 0=No Pain 10=Worst pain imaginable
    Rows

  • FUNCTIONAL DISABILITY

    SPECIFIC ACTIVITIESRate the amount of difficulty you experienced performing each of the tasks listed below, over the past week, by circling the number that best describes your difficulty on a scale of 0-10. A zero (0) means you did not experience any difficulty and a ten (10) means it was so difficult you were unable to do it at all.
  • Specific Activities 0= No difficulty 10=Unable to do
    Rows

  • USUAL ACTIVITIESRate the amount of difficulty you experienced performing your usual activities in each of the areas listed below, over the past week, by circling the number that best describes your difficulty on a scale of 0-10. By “usual activities”, we mean the activities that you performed before you started having a problem with your arm. A zero (0) means you did not experience any difficulty and a ten (10) means it was so difficulty you were unable to do any of your usual activities.

  • Usual Activities 0= No difficulty 10=Unable to do
    Rows
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Should be Empty: