Quick Dash Initial Form | Pro-Motion Physical Therapy

QuickDash (Initial)

Patient Name:

ID #

Date

Instructions

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 selecting the appropriate answer.
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.

No pain = 0, Severe Pain = 10

Please rate your pain level with activity

		NO DIFFICULTY	MILD DIFFICULTY	MODERATE DIFFICULTY	SEVERE DIFFICULTY	UNABLE
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.).

		NOT AT ALL	SLIGHTLY	MODERATELY	QUITE A BIT	EXTREMELY
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?.

		NOT LIMITED AT ALL	SLIGHTLY LIMITED	MODERATELY LIMITED	VERY LIMITED	UNABLE
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?.

	Please rate the severity of the following symptoms in the last week.	NONE	MILD	MODERATE	SEVERE	EXTREME
9.	Arm, shoulder or hand pain.
10.	Tingling (pins and needles) in your arm, shoulder or hand.

		NONE	MILD	MODERATE	SEVERE DIFFICULTY	SO MUCH DIFFFICULTY THAT I CAN’T SLEEP
11.	During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number)