Date of completion

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

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.
Do heavy household chores (eg wash walls, wash floors)
No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
3.
Carry a shopping bag or briefcase
No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
4.
Wash your back
No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
5.
Use a knife to cut food
No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable
6.

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
 

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? Not at all Slightly Moderately Quite a bit Extremely
 

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?

Not limited at all Slightly limited Moderately limited Very limited Unable
Please rate the severity of the following symptoms in the last week
9. Arm, shoulder or hand pain None Mild Moderate Severe Extreme
10.

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

None Mild Moderate Severe Extreme
 
11.

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 difficulty I can't sleep

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

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Disabilies of the Arm, Shoulder and Hand (quickdash) Score  

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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.