NSR — Upper Extremity Function — QuickDASH
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Patient Information

QuickDASH — Upper Extremity Function

Instructions: Please rate your ability to do the following activities in the past week by selecting the number that best describes your ability. Use the scale: 1= No difficulty  ·  2= Mild difficulty  ·  3= Moderate difficulty  ·  4= Severe difficulty  ·  5= Unable to do
Activity / Symptom 1 No Difficulty 2 Mild 3 Moderate 4 Severe 5 Unable
Open a tight or new jar
Do heavy household chores (such as washing walls, washing floors)
Carry a shopping bag or briefcase
Wash your back
Use a knife to cut food
Recreational activities which required some force or impact through your arm, shoulder, or hand (such as hammering, tennis, etc.)
Shoulder, arm, or hand pain
Tingling (pins and needles) in your arm, shoulder, or hand
Sleep difficulties due to arm, shoulder, or hand pain or problems
Feeling less capable, less confident, or less useful because of your arm, shoulder, or hand problem
Recreational activities in which you move your arm freely (such as playing frisbee, badminton, etc.)

✓   End of Patient Questionnaire

Thank you for completing this questionnaire. Please return this form to your therapist.
The scoring section below is for clinician use only.

🔒   CLINICIAN USE ONLY — Complete the score fields below after the patient finishes this questionnaire.
🔒   CLINICIAN USE ONLY — Complete the score fields below after the patient finishes this questionnaire.
🔒   CLINICIAN USE ONLY — Complete the score fields below after the patient finishes this questionnaire.
Scoring: Score = ((Sum of n responses / n) − 1) × 25. If more than one item is unanswered, the scale cannot be scored. Minimum score = 0 (no disability); Maximum = 100 (most severe disability).
MCID: 15.9–16.7 points. A score change of ≥16 points indicates a clinically meaningful change.

Source: Beaton DE et al. J Bone Joint Surg Am. 2005;87(5):1038–1046. © Institute for Work & Health (IWH), Toronto. Free for clinical use. www.dash.iwh.on.ca

Optional QuickDASH Work Module

Complete this section only if you perform paid or unpaid work. Rate the difficulty of the following in the past week due to your arm, shoulder, or hand problem.
Work Activity 1 No Difficulty 2 Mild 3 Moderate 4 Severe 5 Unable / Not Applicable
Using your usual technique for your work
Doing your usual work because of arm, shoulder, or hand pain
Doing your work as well as you would like

Optional QuickDASH Sport/Performing Arts Module

Complete this section only if you participate in sport or play a musical instrument. Rate difficulty in the past week.
Sport / Arts Activity 1 No Difficulty 2 Mild 3 Moderate 4 Severe 5 Unable / Not Applicable
Using your usual technique for playing your instrument or sport
Playing your instrument or sport because of arm, shoulder, or hand pain
Playing your instrument or sport as well as you would like
Spending your usual amount of time practicing or playing

Form 10 of 11  ·  Next Step Rehab Patient Intake Suite  ·  www.nextstep-rehab.com