QuickDASH

QuickDASH

Quick Disabilities Score for the Arm, Shoulder and Hand
Name

First NameLast Name
Email
example@example.com
Today's Date

MonthDayYear
Date
If you are completing this form regarding a different date, enter it here (Month, Day, Year)

MonthDayYear
Date
Please indicate which part of your body this survey is about:

Other
If you answered "other", which area of your body?
Body area affected
Please indicate which side of your body this survey is about:
VAS: Overall, how bad is your pain (0=no pain, 100 =maximum imaginable pain)

Please rate your ability to do the following activities during the last week:

Rows	No difficulty	Mild difficulty	Moderate difficulty	Severe difficulty	Unable to do
1. Open a tight or new jar
2. Do heavy household chores (e.g. wash walls, wash floors)
3. Carry a shopping bag or briefcase
4. Wash your back
5. Use a knife to cut food
6. Recreational activities which require some force, (eg. golf, hammering, tennis, etc)

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?

Rows	None	Slight	Moderate	Severe	Extreme
7. Interference with normal social activities

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?

Rows	None	Mild	Moderate	Severe	Extreme
8. Interference with regular daily activities

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

Rows	None	Mild	Moderate	Severe	Extreme
9. Arm, shoulder, or hand pain
10. Tingling (pins and needles) in your arm, shoulder, or hand

Quality of sleep

Rows	None	Mild difficulty	Moderate difficulty	Severe difficulty	Extreme, unable to sleep
11. Over the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?

Overall QuickDASH Score
Should be Empty: