Upper Extremity Questionnaire

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* 1. Client name: Surname, First Name

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* 2. 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, by selecting the appropriate number.

If you did not have the opportunity to perform an activity in the past week, please make your best estimate of 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 by selecting the number below the appropriate response.

  no difficulty 1 mild difficulty 2 moderate difficulty 3 severe difficulty 4 unable 5
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.).

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* 3. Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.2

  not limited at all 1 slightly 2 moderately 3 quite a bit 4 extremely 5
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?

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

  not limited at all 1 slightly limited 2 moderately limited 3 very limited 4 unable 5
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?

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

  none 1 mild 2 moderate 3 severe 4 extreme 5
Arm, shoulder or hand pain.
Tingling (pins and needles) in your arm, shoulder or hand.

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

  no difficulty 1 mild difficulty 2 moderate difficulty 3 severe difficulty 4 so much difficulty that I can't sleep 5
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?

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* 7. Interpretation of scores (for office use only) 

QuickDASH DISABILITY/SYMPTOM SCORE = ((sum of n responses)/n) - 1) x 25, where n is equal to the number of completed responses.   

((______/______) - 1) x 25 = _________                                                                                                   

A Quick DASH score may not be calculated if there is greater than 1 missing item.                                       
MCID = 8 points.  SCORE RANGE = 0 (no disability) to 100 (max disability)

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* 8. WORK MODULE 

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking if that is your main work role).

Please indicate what your job/work is:

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* 9. Please choose the number that best describes your physical ability in the past week. 
Did you have any difficulty:

  no difficulty 1 mild difficulty 2 moderate difficulty 3 severe difficulty 4 unable 5 N/A - I do not work
using your usual technique for your work?
doing your usual work because of arm, shoulder or hand pain?
doing your work as well as you would like?
spending your usual amount of time doing your work?

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* 10. SPORTS/PERFORMING ARTS MODULE

The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which is most important to you.

Please indicate the sport or instrument which is most important to you:

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* 11. Please circle the number that best describes your physical ability in the past week. 
Did you have any difficulty:

  no difficulty 1 mild difficulty 2 moderate difficulty 3 severe difficulty 4 unable 5 N/A - I do not play a sport or an instrument
using your usual technique for playing your instrument or sport?
playing your musical instrument or sport because of arm, shoulder or hand pain?
playing your musical instrument or sport as well as you would like?
spending your usual amount of time practicing or playing your instrument or sport?

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* 12. Interpretation of scores (for office use only)

SCORING THE OPTIONAL MODULES: ((sum of responses)/4) - 1) x 25.

WORK MODULE = ((_____/4) - 1) x 25 = _______

SPORTS/PERFORMING ARTS MODULE = ((_____/4) - 1) x 25 = _______

An optional module score may not be calculated if there are any missing items.

SCORE RANGE = 0 (no disability) to 100 (max disability)

This questionnaire is taken from: Kennedy CA, Beaton DE, Solway S, McConnell S, Bombardier C. Disabilities of the Arm, Shoulder and Hand (DASH). The DASH and QuickDASH Outcome Measure User’s Manual, Third Edition. Toronto, Ontario: Institute for Work & Health, 2011..

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