Disability of Arms, Shoulders and Hands- Initial Visit
This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer every questions based on your condition in the last week. 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.
Please rate your pain level with activity:
VERY SEVERE PAIN
1 is NO PAIN, 10 is VERY SEVERE PAIN
1. Open a tight or new jar
2. Do heavy household chores (wash walls, floors)
3. Carry a shopping bag or briefcase
4. Wash your back
5. Use a knife to cut food
6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (ex. golf, hammering, tennis, etc.)
NOT AT ALL
QUITE A BIT
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?
NOT AT ALL
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 pain?
Please rate the severity of the following symptoms in the last week:
9. Arm, Shoulder or hand pain.
10. Tingling (pins and needles) in your arm, shoulder or hand.
SO MUCH DIFFICULTY THAT I CAN'T SLEEP
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm