Quick DASH

Quick DASH

This form is used for insurance and data tracking purposes
Patient Name*
Date*

MonthDayYear
Date
INSTRUCTIONS
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 circling 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

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.
Pain level with activity:*
0= No pain, 10= Very Severe Pain
No difficultyMild difficultyModerate difficultySevere difficultyUnable
No difficultyMild difficultyModerate difficultySevere difficultyUnable
No difficultyMild difficultyModerate difficultySevere difficultyUnable
No difficultyMild difficultyModerate difficultySevere difficultyUnable
No difficultyMild difficultyModerate difficultySevere difficultyUnable
No difficultyMild difficultyModerate difficultySevere difficultyUnable
Not at allSlightlyModeratelyQuite a bitExtremely
Not limited at allSlightly limitedModerately limitedVery limitedUnable
Please rate the severity of the following symptoms in the last week.
NoneMildModerateSevereExtreme
NoneMildModerateSevereExtreme
NoneMildModerateSeverely difficultSo much difficulty that I can't sleep
Treating physical therapist
Should be Empty:

Please rate the severity of the following symptoms in the last week.