DASH Score – Disabilities of the Arm, Shoulder and Hand Please rate your ability to do the following activities in the last week by checking the number beside the appropriate response. Name* First Last Your Physical Therapist*Dr. Paul OchoaDr. Monique DupreeDr. Thom WalshDr. Morgan LockerYour Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201. Open a tight or new jar.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 12. Write.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 23. Turn a key.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 34. Prepare a meal.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 45. Push open a heavy door.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 56. Place an object on a shelf above your head.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 67. Do heavy household chores (e.g., wash walls, wash floors).*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 78. Garden or do yard work.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 89. Make a bed.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 910. Carry a shopping bag or briefcase.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 1011. Carry a heavy object (over 10 lbs).*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 1112. Change a lightbulb overhead.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 1213. Wash or blow dry your hair.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 1314. Wash your back.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 1415. Put on a pullover sweater.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 1516. Use a knife to cut food.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 1617. Recreational activities which require little effort (e.g., cardplaying, knitting, etc.).*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 1718. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 1819. Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.).*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 1920. Manage transportation needs (getting from one place to another).*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 2021. Sexual activities.*No DifficultyMild DifficultyModerate DifficultySevere DifficultyUnableClear AnswersNumber 2122. 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? (circle number)*Not At AllSlightlyModeratelyQuite A BitExtremelyClear AnswersNumber 2223. 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 AllSlightly LimitedModerately LimitedVery LimitedUnableClear AnswersNumber 23Please rate the severity of the following 5 symptoms in the last week. (# 24 thru # 28 )24. Arm, shoulder or hand pain.*NoneMildModerateSevereExtremeClear AnswersNumber 2425. Arm, shoulder or hand pain when you performed any specific activity.*NoneMildModerateSevereExtremeClear AnswersNumber 2526. Tingling (pins and needles) in your arm, shoulder or hand.*NoneMildModerateSevereExtremeClear AnswersNumber 2627. Weakness in your arm, shoulder or hand.*NoneMildModerateSevereExtremeClear AnswersNumber 2728. Stiffness in your arm, shoulder or hand.*NoneMildModerateSevereExtremeClear AnswersNumber 2829. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?*No DifficultyMild DifficultyModerate DifficultySevere DifficultySo Much Difficulty That I Can't SleepClear AnswersNumber 2930. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem.*Strongly DisagreeDisagreeNeither Agree Or DisagreeAgreeStrongly AgreeClear AnswersNumber 30DASH Score( [(sum of n responses / n) - 1] x 25, where n is the number of completed responses.)Over the last 2 weeks, how often have you been bothered by the following problems?Little interest or pleasure in doing things*Not at allSeveral DaysMore than half daysNearly every dayFeeling down, depressed or hopeless*Not at allSeveral DaysMore than half daysNearly every dayPHQ 2 Score
