Disability of Shoulder, Arm, or Hand Form (Quick Dash)

Please Do Not Print This Form. Thank you for completing this patient-reported outcome questionnaire. Your responses help your provider determine the best treatment options and track your recovery progress over time. Please answer each of the questions included on this form.

ALL QUESTIONS MUST BE ANSWERED

Name: *

First

Middle

Last

Date

Did you have surgery for this issue PRIOR TO receiving physical therapy? *

Yes
No

PAIN SCORE: Over the past 24 hours, how bad has your pain been? *

Check the number that best represents your pain. 0 = NO PAIN, 10 = WORST IMAGINABLE PAIN

PLEASE RATE YOUR ABILITY TO DO THE FOLLOWING ACTIVITIES IN THE LAST WEEK

Mark the box that corresponds to the most appropriate response in each row.

1. OPEN A TIGHT OR NEW JAR *

2. DO HEAVY HOUSEHOLD CHORES (E.G. WASH WALLS, WASH FLOORS) *

3. CARRY A SHOPPING BAG OR BRIEFCASE *

4. WASH YOUR BACK *

5. USE A KNIFE TO CUT FOOD *

6. RECREATIONAL ACTIVITIES IN WHICH YOU TAKE SOME FORCE OR IMPACT THROUGH THE SHOULDER, HAND OR ARM (GOLF, HAMMERING, TENNIS, ETC.) *

7. 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? *

8. DURING THE PAST WEEK, WERE YOU LIMITED IN YOUR WORK OF OTHER REGULAR DAILY ACTIVITIES AS A RESULT OF YOUR ARM, SHOULDER OR HAND PROBLEM? *

9. ARM, SHOULDER, OR HAND PAIN *

10. TINGLING (PINS AND NEEDLES) IN YOUR ARM, SHOULDER, OR HAND *

11. DURING THE PAST WEEK, HOW MUCH DIFFICULTY HAVE YOU HAD SLEEPING BECAUSE OF PAIN IN YOUR ARM, SHOULDER, OR HAND? *