QuickDASH
Quick Disabilities Score for the Arm, Shoulder and Hand
Name
*
First Name
Last Name
Email
*
example@example.com
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If you are completing this form regarding a different date, enter it here (Month, Day, Year)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your height? (specify in or cm)
What is your current weight? (specify kg or lb)
Please indicate which part of your body this survey is about:
*
Shoulder
Elbow
Wrist
Hand
Other
If you answered "other", which area of your body?
Body area affected
Please indicate which side of your body this survey is about:
*
Left
Right
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
Submit
Should be Empty: