Patient Form
DISABILITIES OF THE ARM, SHOULDER & HAND
Innovative Physical Therapy LLC
Name:
*
First
Last
Please rate your ability to do the following activities in the last week by selecting the number for the appropriate response.
Open a tight or new jar
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Write
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Turn a key
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Prepare a meal
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Push open a heavy door
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Place an object on a shelf above your head
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Do heavy household chores (e.g., wash walls, wash floors)
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Garden or do yard work
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Make a bed
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Carry a shopping bag or briefcase
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Carry a heavy object (over 10 lbs)
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Change a lightbulb overhead
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Wash or blow dry your head
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Wash your back
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Put on a pullover sweater
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Use a knife to cut food
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Recreational activities which require little effort (e.g., cardplaying, knitting, etc.)
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g., golf, hammering, tennis, etc.)
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.)
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Manage transportation needs (getting from one place to another)
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
Sexual activities
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable
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?
1 - Not at all
2 - Slightly
3 - Moderately
4 - Quite a bit
5 - Extremely
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?
1 - Not limited at all
2 - Slightly limited
3 - Moderately limited
4 - Very limited
5 - Unable
Please rate the severity of the following symptoms in the last week.
Arm, shoulder or hand pain
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme
Arm, shoulder or hand pain when you performed any specific activity
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme
Tingling (pins and needles) in your arm, shoulder or hand
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme
Weakness in your arm, shoulder or hand
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme
Stiffness in your arm, shoulder or hand
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - So much difficulty that I can't sleep
I feel less capable, less confident or less useful because of my arm, shoulder or hand problem
1 - Strongly disagree
2 - Disagree
3 - Neither agree nor disagree
4 - Agree
5 - Strongly agree
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