Complete at Therapist Request Please enable JavaScript in your browser to complete this form.Client Name *Please Rate your ability to do the following activities in the last week by indicating the number for the appropriate response 1= No Difficulty, 2=Mild Difficulty, 3=Moderate Difficulty, 4=Severe Difficulty, 5=Unable 1. Open a tight or new jar Selected Value: 1 2. Do heavy household chores (e.g wash walls, floors) Selected Value: 1 3. Carry a shopping bag or briefcase Selected Value: 1 1= No Difficulty, 2=Mild Difficulty, 3=Moderate Difficulty, 4=Severe Difficulty, 5=Unable4. Wash your back Selected Value: 1 5. Use a knife to cut Selected Value: 1 6. Recreational activities in which you take some force or impact through your arm, shoulder, or hand (eg golf, hammering, etc) Selected Value: 1 1= No Difficulty, 2=Mild Difficulty, 3=Moderate Difficulty, 4=Severe Difficulty, 5=Unable 7. 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? Selected Value: 1 1= Not at All, 2=Slightly, 3=Moderately, 4=Quite a Bit, 5=Extremely 8. During the past week, were you limted in your work or other regular daily actiities as a result of your arm, shoulder, or hand problem? Selected Value: 1 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 9. Arm, shoulder or hand pain Selected Value: 1 1=None, 2=Mild, 3=Moderate, 4=Severe, 5= Extreme10. Tingling (Pins and Needles) in your arm, shoulder, or hand Selected Value: 1 1=None, 2=Mild, 3=Moderate, 4=Severe, 5= Extreme 11. During the past week, how much difficulty have you had sleeping because of pain in your arm, shoulder or hand? Selected Value: 1 1=No Difficulty, 2=Mild Difficulty, 3=Moderate Difficulty, 4=Severe Difficulty, 5=So Much Difficulty That I Can't SleepSubmit
