Quick DASH

Quick DASH

This form is used for insurance and data tracking purposes
Patient Name*
Date*

MonthDayYear
Date
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, by circling 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

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.
Pain level with activity:*
0= No pain, 10= Very Severe Pain
Open a tight or new jar:*

No difficultyMild difficultyModerate difficultySevere difficultyUnable
Do heavy household chores (e.g. wash walls, floors).*

No difficultyMild difficultyModerate difficultySevere difficultyUnable
Carry a shopping bag or briefcase*

No difficultyMild difficultyModerate difficultySevere difficultyUnable
Wash your back*

No difficultyMild difficultyModerate difficultySevere difficultyUnable
Use a knife to cut food*

No difficultyMild difficultyModerate difficultySevere difficultyUnable
Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g., Golf, hammering, tennis, etc.)*

No difficultyMild difficultyModerate difficultySevere difficultyUnable
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 allSlightlyModeratelyQuite a bitExtremely
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?*

Not limited at allSlightly limitedModerately limitedVery limitedUnable
Please rate the severity of the following symptoms in the last week.
Arm, shoulder or hand pain*

NoneMildModerateSevereExtreme
Tingling (pins and needles) in your arm, shoulder or hand.*

NoneMildModerateSevereExtreme
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?*

NoneMildModerateSeverely difficultSo much difficulty that I can't sleep
Treating physical therapist
Should be Empty:

Quick DASH

INSTRUCTIONS

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