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The Disabilities of the Arm, Shoulder and Hand (DASH) Score
Jared Larsen
2020-09-28T21:38:00+00:00
The Disabilities of the Arm, Shoulder and Hand (DASH) Score
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Name
*
Name
First
Last
Please select your case manager
*
Please select your case manager
Choose one
Alma Orozco
Ashley Orozco
Bree Campbell
Brenda Rodriguez
Chase Dunakin
Chase Hebdon
Cindy Joyner
Elizabeth Miller
Hailey Moore
Jared Larsen
Jose Nava
Josh Esteron
Lucero Sanchez
Luis Cruz
Maria Martinez
Michele Mesaros
Monica Guerrero
Veronica Barajas
Other
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. 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 you ability regardless of how you perform the task.
1. Open a tight or new jar
*
Please rate your ability to do the following activities in the last week.
1. Open a tight or new jar
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
2. Write
*
Please rate your ability to do the following activities in the last week.
2. Write
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
3. Turn a key
*
Please rate your ability to do the following activities in the last week.
3. Turn a key
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
4. Prepare a meal
*
Please rate your ability to do the following activities in the last week.
4. Prepare a meal
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
5. Push open a heavy door
*
Please rate your ability to do the following activities in the last week.
5. Push open a heavy door
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
6. Place an object on a shelf above your head
*
Please rate your ability to do the following activities in the last week.
6. Place an object on a shelf above your head
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
7. Do heavy household chores (e.g. wash walls, wash floors)
*
Please rate your ability to do the following activities in the last week.
7. Do heavy household chores (e.g. wash walls, wash floors)
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
8. Garden or do yard work
*
Please rate your ability to do the following activities in the last week.
8. Garden or do yard work
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
9. Make a bed
*
Please rate your ability to do the following activities in the last week.
9. Make a bed
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
10. Carry a shopping bag or briefcase
*
Please rate your ability to do the following activities in the last week.
10. Carry a shopping bag or briefcase
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
11. Carry a heavy object (over 10 lbs)
*
Please rate your ability to do the following activities in the last week.
11. Carry a heavy object (over 10 lbs)
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
12. Change a light bulb overhead
*
Please rate your ability to do the following activities in the last week.
12. Change a light bulb overhead
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
13. Wash or blow dry your hair
*
Please rate your ability to do the following activities in the last week.
13. Wash or blow dry your hair
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
14. Wash your back
*
Please rate your ability to do the following activities in the last week.
14. Wash your back
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
15. Put on a pullover sweater
*
Please rate your ability to do the following activities in the last week.
15. Put on a pullover sweater
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
16. Use a knife to cut food
*
Please rate your ability to do the following activities in the last week.
16. Use a knife to cut food
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
17. Recreational activities which require little effort (e.g. cardplaying, knitting, etc)
*
Please rate your ability to do the following activities in the last week.
17. Recreational activities which require little effort (e.g. card playing, knitting, etc)
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
18. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g. golf, hammering, tennis, etc)
*
Please rate your ability to do the following activities in the last week.
18. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g. golf, hammering, tennis, etc)
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
19. Recreational activities in which you move your arm freely (e.g. playing Frisbee, badminton, etc)
*
Please rate your ability to do the following activities in the last week.
19. Recreational activities in which you move your arm freely (e.g. playing Frisbee, badminton, etc)
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
20. Manage transportation needs (getting from one place to another)
*
Please rate your ability to do the following activities in the last week.
20. Manage transportation needs (getting from one place to another)
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
21. Sexual activities
Please rate your ability to do the following activities in the last week.
21. Sexual activities
(This question is optional)
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
22. 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?
*
22. 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 at all
Slightly
Moderately
Quite a bit
Extremely
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?
*
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?
No difficulty
Mild difficulty
Moderate Difficulty
Severe Difficulty
Unable
24. Arm, shoulder or hand pain in the last week?
*
Please rate the severity of the following symptoms in the last week.
24. Arm, shoulder or hand pain in the last week?
None
Mild
Moderate
Severe
Extreme
25. Arm, shoulder or hand pain when you performed any specific activity in the last week?
*
Please rate the severity of the following symptoms in the last week.
25. Arm, shoulder or hand pain when you performed any specific activity in the last week?
None
Mild
Moderate
Severe
Extreme
26. Tingling (pins and needles) in your arm, shoulder or hand in the last week?
*
Please rate the severity of the following symptoms in the last week.
26. Tingling (pins and needles) in your arm, shoulder or hand in the last week?
None
Mild
Moderate
Severe
Extreme
27. Weakness in your arm, shoulder or hand in the last week?
*
Please rate the severity of the following symptoms in the last week.
27. Weakness in your arm, shoulder or hand in the last week?
None
Mild
Moderate
Severe
Extreme
28. Stiffness in your arm, shoulder or hand in the last week?
*
Please rate the severity of the following symptoms in the last week.
28. Stiffness in your arm, shoulder or hand in the last week?
None
Mild
Moderate
Severe
Extreme
29. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?
*
29. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
So much I can't sleep
30. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem
*
30. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem
Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Medication
Please list all the medication you are taking for your injury
Please list the name of each medication. The frequency you are taking it. (e.g. 1x daily or 3x weekly etc.) and the duration. (How long have you been taking it.)
Medication Name
Frequency
Duration
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The Disabilities of the Arm, Shoulder and Hand (DASH) Score