Sending Patient QuickDASH Form

QuickDASH - Initial

Instructions

  • 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 selecting the appropriate answer.
  • 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.

 

No pain = 0, Severe Pain = 10

Please rate your pain level with activity

1. Open a tight or new jar.

2. Do heavy household chores (e.g., 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(e.g., 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?.

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?.

Please rate the severity of the following symptoms in the last week.

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 number)

    NO DIFFICULTY MILD DIFFICULTY MODERATE DIFFICULTY SEVERE DIFFICULTY UNABLE
1. Open a tight or new jar.
2. Do heavy household chores (e.g., 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(e.g., golf, hammering, tennis, etc.).
    NOT AT ALL SLIGHTLY MODERATELY QUITE A BIT EXTREMELY
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 LIMITED AT ALL SLIGHTLY LIMITED MODERATELY LIMITED VERY LIMITED UNABLE
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?.
  Please rate the severity of the following symptoms in the last week. NONE MILD MODERATE SEVERE EXTREME
9. Arm, shoulder or hand pain.
10. Tingling (pins and needles) in your arm, shoulder or hand.
    NONE MILD MODERATE SEVERE DIFFICULTY SO MUCH DIFFFICULTY THAT I CAN’T SLEEP
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number)