Shoulder

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Upper Body- DASH

1
Primary Clinic* This field is required
Boulder
Broomfield
Englewood
Lafayette
Longmont
Wheat Ridge
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2
Name* This field is required
First Name
Last Name
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3
Total:
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4
Percentage of Disability:
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5
Please rate your pain level with activity* This field is required
1
2
3
4
5
6
7
8
9
10
Best
Worst
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6
How difficult is it to perform the following task?* This field is required
(5) Unable
(4) Severe
(3) Moderate
(2) Mild
(1) No Difficulty
1. Open a tight or new jar
2. Do heavy household chores (eg, wash walls, 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 your arm, shoulder or hand (eg golf, hammering, tennis etc.)
1. Open a tight or new jar
2. Do heavy household chores (eg, wash walls, 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 your arm, shoulder or hand (eg golf, hammering, tennis etc.)
(5) Unable
(4) Severe
(3) Moderate
(2) Mild
(1) No Difficulty
(5) Unable
(4) Severe
(3) Moderate
(2) Mild
(1) No Difficulty
(5) Unable
(4) Severe
(3) Moderate
(2) Mild
(1) No Difficulty
(5) Unable
(4) Severe
(3) Moderate
(2) Mild
(1) No Difficulty
(5) Unable
(4) Severe
(3) Moderate
(2) Mild
(1) No Difficulty
(5) Unable
(4) Severe
(3) Moderate
(2) Mild
(1) No Difficulty
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7
During the last week to what extent has your arm shoulder or hand problem:* This field is required
(5) Extremely
(4) Very
(3) Moderately
(2) Slightly
(1) Not at all
Interfered with your normal social activities with family, friends, neighbors or groups?
Limited you in your work or other regular daily activities
Caused you pain
Caused tingling (pins and needles)
Caused difficulty sleeping because of pain
Interfered with your normal social activities with family, friends, neighbors or groups?
Limited you in your work or other regular daily activities
Caused you pain
Caused tingling (pins and needles)
Caused difficulty sleeping because of pain
(5) Extremely
(4) Very
(3) Moderately
(2) Slightly
(1) Not at all
(5) Extremely
(4) Very
(3) Moderately
(2) Slightly
(1) Not at all
(5) Extremely
(4) Very
(3) Moderately
(2) Slightly
(1) Not at all
(5) Extremely
(4) Very
(3) Moderately
(2) Slightly
(1) Not at all
(5) Extremely
(4) Very
(3) Moderately
(2) Slightly
(1) Not at all
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