Skagit_QuickDASH

Client Name

Date

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

Questions #1-6

Rows	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

Rows	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

Rows	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)

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

Question #11

Rows	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)