russettrehab_QuickDASH

Client Name

Date

Health Card #

FOR THE ARM WE ARE TREATING please rate your ability to do the following activities in the last week by circling the

number below the appropriate response. Please answer ALL questions.

	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.).

	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?

	NOT 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.

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

Type a question

	NoDifficulty	MildDifficulty	ModerateDifficulty	SevereDifficulty	I CANTSLEEP
How much difficulty have you had sleeping because of the pain in your arm,shoulder or hand.