Quick Dash
Full Name
*
First Name
Last Name
1. Open a tight or new jar.
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
2. Do heavy household chores (e.g., wash walls, floors).
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
3. Carry a shopping bag or briefcase.
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
4. Wash your back.
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
5. Use a knife to cut food.
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
7. 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?
Not at all
Slightly
Moderately
Quite a Bit
Extremely
8. 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?
Not Limited at All
Slightly Limited
Moderately Limited
Very Limited
Unable
9. Arm, shoulder or hand pain.
None
Mild
Moderate
Severe
Extreme
10. Tingling (pins and needles) in your arm, shoulder or hand.
None
Mild
Moderate
Severe
Extreme
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
So Much Difficulty that I Can't Sleep
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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 indicate what your job/work is:
If you do not work, please skip this question.
Did you have any difficulty:
1. using your usual technique for your work?
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
2. doing your usual work because of arm, shoulder or hand pain?
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
3. doing your work as well as you would like?
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
4. spending your usual amount of time doing your work?
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
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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 indicate the sport or instrument which is most important to you:
If you do not play a sport or an instrument. (You may skip this section.)
Did you have any difficulty:
1. using your usual technique for playing your instrument or sport?
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
2. playing your musical instrument or sport because of arm, shoulder or hand pain?
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
3. playing your musical instrument or sport as well as you would like?
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
4. spending your usual amount of time practising or playing your instrument or sport?
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable
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