telmagrant_QuickDASH

QuickDASH

For Shoulder, Elbow, Wrist and Hand
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 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.
Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.

Questions #1-6

	NO DIFFICULTY	MILD DIFFICULTY	MODERATE DIFFICULTY	SERVERE DIFFICULTY	UNABLE
Open a tight or new jar.
Do heavy household chores (e.g., wash walls, floors).
Carry a shopping bag or briefcase.
Wash your back.
Use a knife to cut food.
Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).

Question #7

	NOT AT ALL	SLIGHTLY	MODERATELY	QUIET A BIT	EXTREMELY
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?

Question #8

	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?

Please rate the severity of the following symptoms in the last week. (select number)

	NONE	MILD	MODERATE	SEVERE	EXTREME
Arm, shoulder or hand pain.
Tingling (pins and needles) in your arm, shoulder or hand.

Question #11

	NO DIFFICULTY	MILD DIFFICULTY	MODERATE DIFFICULTY	SEVERE DIFFICULTY	SO MUCH DIFFICULTY THAT I CAN'T SLEEP
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number)

NUMERICAL PAIN RATING SCALE (NPRS)
Patient Name
Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Staff: To get Total Score: Add value of each answer then see the Quick DASH Scoring Sheet for % of Disability. Record Disability in PPS Assessment Form

With respect to your pain, over the last 24 hours, how bad has your pain been?

	NO PAIN 0	MILD 1-3	MODERATE 4	SEVERE 5-6	VERY SEVERE 7-9	WORST POSSIBLE PAIN 10
Select appropriate number

QuickDASH