DISABILITIES OF THE ARM, SHOULDER AND HAND

    Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.

    Activities

    NO DIFFICULTY

    MILD DIFFICULTY

    MODERATE DIFFICULTY

    SEVERE DIFFICULTY

    UNABLE

    1. Open a tight or new jar.

    1

    2

    3

    4

    5

    2. Write.

    1

    2

    3

    4

    5

    3. Turn a key.

    1

    2

    3

    4

    5

    4. Prepare a meal.

    1

    2

    3

    4

    5

    5. Push open a heavy door.

    1

    2

    3

    4

    5

    6. Place an object on a shelf above your head.

    1

    2

    3

    4

    5

    7. Do heavy household chores (e.g., wash walls, wash floors).

    1

    2

    3

    4

    5

    8. Garden or do yard work.

    1

    2

    3

    4

    5

    9. Make a bed.

    1

    2

    3

    4

    5

    10. Carry a shopping bag or briefcase.

    1

    2

    3

    4

    5

    11. Carry a heavy object (over 10 lbs).

    1

    2

    3

    4

    5

    12. Change a lightbulb overhead.

    1

    2

    3

    4

    5

    13. Wash or blow dry your hair.

    1

    2

    3

    4

    5

    14. Wash your back.

    1

    2

    3

    4

    5

    15. Put on a pullover sweater.

    1

    2

    3

    4

    5

    16. Use a knife to cut food.

    1

    2

    3

    4

    5

    17. Recreational activities which require little effort (e.g., cardplaying, knitting, etc.).

    1

    2

    3

    4

    5

    18. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).

    1

    2

    3

    4

    5

    19. Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.).

    1

    2

    3

    4

    5

    20. Manage transportation needs (getting from one place to another).

    1

    2

    3

    4

    5

    21. Sexual activities.

    1

    2

    3

    4

    5

    DISABILITIES OF THE ARM, SHOULDER AND HAND

    Activities

    NOT AT ALL

    SLIGHTLY

    MODERATELY

    QUITE A BIT

    EXTREMELY

    22. 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? (circle number)

    1

    2

    3

    4

    5

    Activities

    NOT LIMITED AT ALL

    SLIGHTLY LIMITED

    MODERATELY LIMITED

    VERY LIMITED

    UNABLE

    23. 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? (circle number)

    1

    2

    3

    4

    5

    Activities

    NONE

    MILD

    MODERATE

    SEVERE

    EXTREME

    24. Arm, shoulder or hand pain

    1

    2

    3

    4

    5

    25. Arm, shoulder or hand pain when you performed any specific activity.

    1

    2

    3

    4

    5

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

    1

    2

    3

    4

    5

    27. Weakness in your arm, shoulder or hand.

    1

    2

    3

    4

    5

    28. Stiffness in your arm, shoulder or hand.

    1

    2

    3

    4

    5

    Activities

    NO DIFFICULTY

    MILD DIFFICULTY

    MODERATE DIFFICULTY

    SEVERE DIFFICULTY

    SO MUCH DIFFICULTY THAT I CAN’T SLEEP

    29. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number)

    1

    2

    3

    4

    5

    Activities

    STRONGLY DISAGREE

    DISAGREE

    NEITHER AGREE NOR DISAGREE

    AGREE

    STRONGLY AGREE

    30. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem. (circle number)

    1

    2

    3

    4

    5

    DISABILITIES OF THE ARM, SHOULDER AND HAND

    WORK MODULE (OPTIONAL)

    The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking
    if that is your main work role).

    Please indicate what your job/work is:

    I do not work. (You may skip this section.)

    Please circle the number that best describes your physical ability in the past week. Did you have any difficulty:

    Activities

    NO DIFFICULTY

    MILD DIFFICULTY

    MODERATE DIFFICULTY

    SEVERE DIFFICULTY

    UNABLE

    1. using your usual technique for your work?

    1

    2

    3

    4

    5

    2. doing your usual work because of arm, shoulder or hand pain?

    1

    2

    3

    4

    5

    3. doing your work as well as you would like?

    1

    2

    3

    4

    5

    4. spending your usual amount of time doing your work?

    1

    2

    3

    4

    5

    SPORTS/PERFORMING ARTS MODULE (OPTIONAL)

    The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or
    both.

    If you play more than one sport or instrument (or play both), please answer with respect to that activity which is most important to
    you.

    If you play more than one sport or instrument (or play both), please answer with respect to that activity which is most important to
    you.

    I do not play a sport or an instrument. (You may skip this section.)

    Please circle the number that best describes your physical ability in the past week. Did you have any difficulty:

    Activities

    NO DIFFICULTY

    MILD DIFFICULTY

    MODERATE DIFFICULTY

    SEVERE DIFFICULTY

    UNABLE

    1. using your usual technique for playing your instrument or sport?

    1

    2

    3

    4

    5

    2. playing your musical instrument or sport because of arm, shoulder or hand pain?

    1

    2

    3

    4

    5

    3. playing your musical instrument or sport as well as you would like?

    1

    2

    3

    4

    5

    4. spending your usual amount of time practising or playing your instrument or sport?

    1

    2

    3

    4

    5

    SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by
    4 (number of items); subtract 1; multiply by 25.

    An optional module score may not be calculated if there are any missing items.

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