Disabilities of the arm, shoulder and hand Phil Rees or Mitch Bowd will ask you to complete the below form IF required. If you are unsure, please phone our rooms on (02) 4923 8999. DISABILITIES OF THE ARM, SHOULDER AND HANDName(Required)Date of Birth(Required) DD slash MM slash YYYY This questionnaire asks about your symptoms as well as your ability to perform certain activities. Instructions 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 on 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. Please rate your ability to do the following activities in the last week. Rating12345 Meaning No Difficulty Mild DifficultyModerate DifficultySevere DifficultyUnable 1. Open a tight or new jar.(Required) 1 2 3 4 5 2.Write.(Required) 1 2 3 4 5 3. Turn a key.(Required) 1 2 3 4 5 4. Prepare a meal.(Required) 1 2 3 4 5 5. Push open a heavy door.(Required) 1 2 3 4 5 6. Place an object on a shelf above your head.(Required) 1 2 3 4 5 7. Do heavy household chores (e.g., wash walls, wash floors).(Required) 1 2 3 4 5 8. Garden or do yard work.(Required) 1 2 3 4 5 9. Make a bed.(Required) 1 2 3 4 5 10. Carry a shopping bag or briefcase.(Required) 1 2 3 4 5 11. Carry a heavy object (over 10 lbs).(Required) 1 2 3 4 5 12. Change a lightbulb overhead.(Required) 1 2 3 4 5 13. Wash or blow dry your hair.(Required) 1 2 3 4 5 14. Wash your back.(Required) 1 2 3 4 5 15. Put on a pullover sweater.(Required) 1 2 3 4 5 16. Use a knife to cut food.(Required) 1 2 3 4 5 17. Recreational activities which require little effort (e.g., cardplaying, knitting, etc.).(Required) 1 2 3 4 5 18. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).(Required) 1 2 3 4 5 19. Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.).(Required) 1 2 3 4 5 20. Manage transportation needs (getting from one place to another).(Required) 1 2 3 4 5 21. Sexual activities.(Required) 1 2 3 4 5 Prefer to not respond During the past week, to what extent has your arm, shoulder or hand problem interfered with; Rating12345 Meaning Not at all SlightlyModeratelyQuite a bitExtremely 22. 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?(Required) 1 2 3 4 5 During the last week: Rating12345 Meaning Not limited at all Slightly limitedModerately limitedVery limitedUnable 23. 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?(Required) 1 2 3 4 5 Please rate the severity of the following symptoms in the last week. Rating12345 Meaning NoneMildModerateSevereExtreme 24. Arm, shoulder or hand pain.(Required) 1 2 3 4 5 25. Arm, shoulder or hand pain when you performed any specific activity.(Required) 1 2 3 4 5 26. Tingling (pins and needles) in your arm, shoulder or hand.(Required) 1 2 3 4 5 27. Weakness in your arm, shoulder or hand.(Required) 1 2 3 4 5 28. Stiffness in your arm, shoulder or hand.(Required) 1 2 3 4 5 Please rate the severity of the following symptoms in the last week. Rating12345 Meaning No difficultyMild difficultyModerate difficultySevere difficultySo much that I cannot sleep 29. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?(Required) 1 2 3 4 5 In the last week. Rating12345 Meaning Strongly disagreeDisagreeNeither agree nor disagreeAgreeStrongly agree 30. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem.(Required) 1 2 3 4 5 This field is hidden when viewing the formTotalThis field is hidden when viewing the formTotal
