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Signing a Contract

Shoulder / Elbow / Wrist / Hand

Please complete the following:

Shoulder / Elbow / Wrist / Hand

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 checking 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. 

1. Open a tight or new jar:
2. Do heavy household chores (e.g., 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 (e.g. 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 or other regular daily activities as a result of your arm, shoulder, or hand problem?
9. Please rate the severity of your arm, shoulder, or hand pain symptoms in the last week:
10. Please rate the severity of tingling (pins and needles) in your arm, shoulder, or hand in the last week:
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand?

Thanks for submitting! Please let us know what questions you have, otherwise we'll look forward to seeing you soon!

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