Re-Eval
Hands On Therapy
Name
*
First Name
Last Name
Select the 3 tasks that you have the most difficulty performing
*
Getting dressed
Lifting heavy items
Performing household chores
Cooking
Opening jars/cans
Manipulating small items
Reaching overhead
Rate your current level of pain (0=none; 10=hospital)
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
Rate the LOWEST your pain has been in the past 7 days (0=none; 10=hospital)
*
0
1
2
3
4
5
6
7
8
9
10
Rate the HIGHEST your pain has been in the past 7 days (0=none; 10=hospital)
*
0
1
2
3
4
5
6
7
8
9
10
QUICK DASH
Please rate your ability to do the following activities IN THE LAST WEEK
*
No Difficulty (1)
Mild Difficulty (2)
Moderate Difficulty (3)
Severe Difficulty (4)
Unable (5)
Open a tight/new jar
Do heavy household chores
Carry a shopping bag or briefcase
Wash back
Use a knife to cut food
Perform recreational activities in which you take some force/impact through your arm/shoulder/hand
*
Not at All (1)
Slightly (2)
Moderately (3)
Quite a Bit (4)
Extremely (5)
To what extent has your arm/shoulder/hand problems interfered with your normal social activities with friends/family/neighbors/groups?
*
Not Limited at All (1)
Slightly Limited (2)
Moderately Limited (3)
Very Limited (4)
Unable (5)
Were you limited in your work or other regular daily activities as a result of your arm/shoulder/hand problem
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
*
No Difficulty (1)
Mild Difficulty (2)
Moderate Difficulty (3)
Severe Difficulty (4)
So Much Difficulty That I Cannot Sleep (5)
How much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand
Signature of patient/legally responsible person
*
Clear
Date Signed
*
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Month
-
Day
Year
Date
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