The Disabilities of the Arm, Shoulder and Hand (DASH) Score

Name*
Name
First Last
Please select your case manager*
Please select your case manager

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

Medication Name	Frequency	Duration

The Disabilities of the Arm, Shoulder and Hand (DASH) Score

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Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

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Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

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Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

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Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate your ability to do the following activities in the last week.

Please rate the severity of the following symptoms in the last week.

Please rate the severity of the following symptoms in the last week.

Please rate the severity of the following symptoms in the last week.

Please rate the severity of the following symptoms in the last week.

Please rate the severity of the following symptoms in the last week.