The Quick Dash Outcome Measure

1

Name

First Name

Surname

2

Date

3

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 would be the most accurate.

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.

4

Please rate your ability to do the following activities in the last week by selecting the number below the appropriate response.

5

Q 1/ 11 Open a tight or new jar.* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

6

Q 2 / 11 Do heavy household chores (e.g., wash walls, floors).* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

7

Q 3 / 11 Carry a shopping bag or briefcase.* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

9

Q 5 / 11 Use a knife to cut food.* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

10

Q 6 / 11 Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

11

Q 7 / 11 During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours or groups?* This field is required.

Not at all

Slightly

Moderately

Quite a bit

Extremely

12

Q 8 / 11 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?* This field is required.

Not limited at all

Slightly limited

Moderately limited

Very limited

Unable

13

Q 9 / 11 Please rate the severity of the following symptoms in the last week: Arm, shoulder or hand pain.* This field is required.

None

Mild

Moderate

Severe

Extreme

14

Q 10 / 11 Please rate the severity of the following symptoms in the last week: Tingling (pins and needles) in your arm, shoulder or hand* This field is required.

None

Mild

Moderate

Severe

Extreme

15

Q 11 / 11 During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

So much difficulty that I can't sleep

16

Work Module (Optional)

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking if that is your main work role).

Please select the option that best describes your physical ability in the past week.

17

Please Indicate what your job/work is(please skip if you do not work)

18

I do not work.

19

Using your usual technique for your work?* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

20

Doing your usual work because of arm, shoulder or hand pain?* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

21

Doing your work as well as you would like?* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

22

Spending your usual amount of time doing your work?* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

23

SPORTS/Performing Arts Module (Optional)

The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which is most important to you.

Please select the option that best describes your physical ability in the past week.

24

Please indicate the sport or instrument which is most important to you:(You may skip this section if you do not play a sport or an instrument)

25

I do not play a sport or an instrument.

26

Using your usual technique for playing your instrument or sport?* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

27

Playing your musical instrument or sport because of arm, shoulder or hand pain?* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

28

Playing your musical instrument or sport as well as you would like?* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

29

Spending your usual amount of time practising or playing your instrument or sport?* This field is required.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

30

DASH Disability Score PercentageNo Difficulty = 1 Mild Difficulty = 2 Moderate Difficulty = 3 Severe Difficulty = 4 Unable = 5 Score System = ((Sum of responses divide by number of answers) - 1) x 25

31

Work Module (OPTIONAL) Disability Score Percentage

If Score is negative. Please disregard and Score Percentage should be 0

32

Sports/Performing Arts Module (OPTIONAL) Disability Score Percentage

If Score is negative. Please disregard and Score Percentage should be 0