Disabilities Of The Arm, Shoulder And Hand

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Open a tight or new jar

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Write

No Difficulty

Mild Difficulty

Moderate Difficulty

Severe Difficulty

Unable

Turn a key

No Difficulty

Mild Difficulty

Moderate Difficulty

Severe Difficulty

Unable

Prepare a meal

No Difficulty

Mild Difficulty

Moderate Difficulty

Severe Difficulty

Unable

Push open a heavy door

No Difficulty

Mild Difficulty

Moderate Difficulty

Severe Difficulty

Unable

Place an object on a shelf over your head

No Difficulty

Mild Difficulty

Moderate Difficulty

Severe Difficulty

Unable

Do heavy household chores (e.g., wash walls, wash floors)

No Difficulty

Mild Difficulty

Moderate Difficulty

Severe Difficulty

Unable

Do gardening or yard work

No Difficulty

Mild Difficulty

Moderate Difficulty

Severe Difficulty

Unable

Make a bed

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Carry a shopping bag or briefcase

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Carry a heavy object (over 10 lbs)

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Change a lightbulb overhead

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Wash or blow dry your hair

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Wash your back

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Put on a pullover sweater

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Use a knife to cut food

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Recreational activities which require little effort (e.g., card playing, knitting, etc.)

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

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

Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.)

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Manage transportation needs (getting from one place to another)

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Sexual activities

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

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 limited at all

Slightly limited

Moderately limited

Very limited

Unable

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

Mild

Moderate

Severe Extreme

Arm, shoulder or hand pain

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Arm, shoulder or hand pain when you performed any specific activity

None

Mild

Moderate

Severe

Extreme

Tingling (pins and needles) in your arm, shoulder or hand

None

Mild

Moderate

Severe

Extreme

Weakness in your arm, shoulder or hand

None

Mild

Moderate

Severe

Extreme

Stiffness in your arm, shoulder or hand

None

Mild

Moderate

Severe

Extreme

During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?

Not limited at all

Slightly limited

Moderately limited

Very limited

Unable

I feel less capable, less confident or less useful because of my arm, shoulder or hand problem

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree