Upper Extremity Functional Scale
Name
*
First Name
Last Name
Email
example@example.com
Physical Therapist
*
Please Select
Michael Zazzali DSc.PT OCS
Stuart Yeh PT
1. Any of your usual work, housework, or school activities
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
2. Your usual hobbies, re creational or sporting activities
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
3. Lifting a bag of groceries to waist level
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
4. Lifting a bag of groceries above your head
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
5. Grooming your hair
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
6. Pushing up on your hands (eg from bathtub or chair)
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
7. Preparing food (eg peeling, cutting)
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
8. Driving
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
9. Vacuuming, sweeping or raking
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
10. Dressing
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
11. Doing up buttons
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
12. Using tools or appliances
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
13. Opening doors
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
14. Cleaning
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
15. Tying or lacing shoes
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
16. Sleeping
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
17. Laundering clothes (eg washing, ironing, folding)
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
18. Opening a jar
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
19. Throwing a ball
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
20. Carrying a small suitcase with your affected limb
*
Please Select
0. Extreme Difficulty or Unable to Perform Activity
1. Quite a Bit of Difficulty
2. Moderate Difficulty
3. A Little Bit of Difficulty
4. No Difficulty
Signature
Date
-
Month
-
Day
Year
Date
Submit
UEFS Score
Medicare Rating
Should be Empty: