Which Elbow is this form about?

Right               Left

Procedure

Indication (if injury include date of original injury)

During the past 4 weeks ....

On a scale of 1- 100, how bad overall has your elbow been. With 1 being no problem, 100 being incapacitating.

 No problem                                                                    Incapacitating

Quick DASH

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

Please rate your ability to do the following activities in the last week by ticking the box next to the appropriate response.

1. Open a tight or new jar.

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

2. Do heavy household chores (e.g., wash walls, 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 (e.g., 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.

Not limited at all

Slightly limited

Moderately limited

Very limited

Unable

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

Not limited at all

Slightly limited

Moderately limited

Very limited

Unable

11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number)

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

So much difficulty that I can't sleep

QuickDASH DISABILITY/SYMPTOM SCORE = (sum of n responses)/n - 1 x 25, where n is equal to the number
of completed responses.

A QuickDASH score may not be calculated if there is greater than 1 missing item.

WORK MODULE (OPTIONAL)

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including
homemaking if that is your main work role).
Please indicate what your job/work is:

If you do not work. (You may skip this section.)
Please circle the number that best describes your physical ability in the past week.

Did you have any difficulty:

1. using your usual technique for your work?

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

2. doing your usual work because of arm, shoulder or hand pain?

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

3. doing your work as well as you would like?

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

4. spending your usual amount of time doing your work?

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

SPORTS/PERFORMING ARTS MODULE (OPTIONAL)

The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or
sport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which is
most important to you.
Please indicate the sport or instrument which is most important to you:

 
If you do not play a sport or an instrument. (You may skip this section.)
Please circle the number that best describes your physical ability in the past week.

Did you have any difficulty:

1. using your usual technique for playing your instrument or sport?

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

2. playing your musical instrument or sport because
of arm, shoulder or hand pain?

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

3. playing your musical instrument or sport as well as you would like?

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

4. spending your usual amount of time practising or playing your instrument or sport?

No difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Unable

Mayo elbow score

1. Pain (choose one)

None

Examination

Range of motion

Flexion          Extension   Full extension = 0º Use negative value for hyperextension

Pronation   Supination Use a  negative value if fixed deformity less than neutral in any direction