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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 Open a tight or new Turn a Prepare a Push open a heavy Place an object on a shelf above your Do heavy household chores ( , wash walls, wash floors).123458. Garden or do yard Make a Carry a shopping bag or Carry a heavy object (over 10 lbs).1234512. Change a lightbulb Wash or blow dry your Wash your Put on a pullover Use a knife to cut Recreational activities which require little effort ( , cardplaying, knitting, etc.).1234518. Recreational activities in which you take some force or impact through your arm, SHOULDER or hand ( , golf, hammering, tennis, etc.).1234519. Recreational activities in which you move your arm freely ( , playing frisbee, badminton, etc.).1234520. Manage transportation needs (getting from one place to another).1234521. Sexual activities.

DISABILITIES OF THE ARM, SHOULDER AND HAND DASH INSTRUCTIONS This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer every question, based

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  Shoulder, Disabilities, Dash, Disabilities of the arm

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