Quick Dash

Quick Dash

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

Name
Name
First
Last
No Difficulty (1)
Mild Difficulty (2)
Moderate Difficulty (3)
Severe Difficulty (4)
Unable to Do (5)
1. Open a tight or new jar.
2. Do heavy household chores (i.e., wash walls, floors).
3. Carry a shopping bag or briefcase.
4. Wash your back.
5. Use a knife to cut food.
6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (i.e., golf, hammering, tennis etc.).
7. 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?
Not at All (1)
Slightly (2)
Moderately (3)
Quite a Bit (4)
Extremely (5)
7. 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?
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 (1)
Slightly Limited (2)
Moderately Limited (3)
Very Limited (4)
Unable To Do (5)
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?
None (1)
Mild (2)
Moderate (3)
Severe (4)
Extreme (5)
9. Arm, shoulder or hand pain.
10. Tingling (pins and needles) in your arm, shoulder or hand.
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand (circle one)?
No Difficulty (1)
Mild Difficulty (2)
Moderate Difficulty (3)
Severe Difficulty (4)
So Much It Prevents Sleep (5)
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand (circle one)?
Since the beginning of therapy my condition has improved:
During the past 24 hours, my maximum pain rating was: