Date of completion

The Disabilities of the Arm, Shoulder and Hand (DASH) Score

Clinician's name (or ref)
Patient's name (or ref
Patient's d.o.b
 

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. If you did not have the opportunity to perform an activity in the past week, please make your best estimate on 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 you ability regardless of how you perform the task.

Please rate your ability to do the following activities in the last week.
1.
Open a tight or new jar
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
2.
Write
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
3.
Turn a key
No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
4.
Prepare a meal
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
5.
Push open a heavy door
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
6.
Place an object on a shelf above your head
No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable

7.

Do heavy household chores (eg wash walls, wash floors)
 No difficulty Mild difficulty Moderate difficulty Severe difficulty
Unable
 
8.
Garden or do yard work
No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
9.
Make a bed
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
10.
Carry a shopping bag or briefcase
No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
11.
Carry a heavy object (over 10 lbs)
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
12.
Change a lightbulb overhead
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
13.
Wash or blow dry your hair
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
14.
Wash your back
No difficulty Mild difficulty Moderate difficulty Severe difficulty
Unable
 
15.
Put on a pullover sweater
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
16.
Use a knife to cut food
 No difficulty Mild difficulty Moderate difficulty Severe difficulty
Unable

17.

Recreational activities which require little effort (eg cardplaying, knitting, etc)
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable

18.

Recreational activities in which you take some force or impact through your arm, shoulder or hand (eg golf, hammering, tennis, etc)
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable

19.

Recreational activities in which you move your arm freely (eg playing frisbee, badminton, etc)
No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable

20.

Manage transportation needs (getting from one place to another)
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
21.
Sexual activities
 No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
 
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? Not at all Slightly Moderately Quite a bit Extremely
 
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?

Not limited at all Slightly limited Moderately limited Very limited Unable
  Please rate the severity of the following symptoms in the last week  
24. Arm, shoulder or hand pain None Mild Moderate Severe Extreme
25.

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

None Mild Moderate Severe Extreme
26.

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

None Mild Moderate Severe Extreme
27. Weakness in your arm, shoulder or hand None Mild Moderate Severe Extreme
28. Stiffness in your arm, shoulder or hand None Mild Moderate Severe Extreme
 
29.

During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?

No difficulty Mild difficulty Moderate difficulty Severe difficulty So much I can't sleep
 
30.

I feel less capable, less confident or less useful because of my arm, shoulder or hand problem

Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree

Thank you very much for completing all the questions in this questionnaire.

To save this data please print or

 

Disabilies of the Arm, Shoulder and Hand (DASH) Score is  

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Reference: Waddell C, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993; 52:157-168.

Fritz JM, George S. Identifying Psychosocial Variables in Patients With Acute Work-Related Low Back Pain: The Importance of Fear-Avoidance Beliefs. Phys Ther. 2002; 82(10): 973-983.

Lethem J, Slade PD, Troup JDG, Bendey G. Outline of a fear avoidance model of exaggerated pain perceptions, Behav Res Ther. 1983;21:401-408.

Williamson E. Fear Avoidance Behavior Questionnaire. Austrailian Journal of Physiotherapy. 2006; 52: 149.

Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eck H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62: 36, 272.