germantownchiro.com - Quick DASH

Quick DASH

OUTCOME MEASURE
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 circling 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.
Name:
Date:

MonthDayYear
Date
1 = NO DIFFICULTY , 2 = MILD DIFFICULTY, 3 = MODERATE DIFFICULTY, 4 = SVERE DIFFICULTY, 5 = UNABLE
1. Open a tight or new jar

1

2

3

4

5

1 is NO DIFFICULTY, 5 is UNABLE
2. Do heavy household chores (e.g., wash walls, floors).

1

2

3

4

5

1 is NO DIFFICULTY, 5 is UNABLE
3. Carry a shopping bag or briefcase.

1

2

3

4

5

1 is NO DIFFICULTY, 5 is UNABLE
4. Wash your back.

1

2

3

4

5

1 is NO DIFFICULTY, 5 is UNABLE
5. Use a knife to cut food.

1

2

3

4

5

1 is NO DIFFICULTY, 5 is UNABLE
6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).

1

2

3

4

5

1 is NO DIFFICULTY, 5 is UNABLE
1= NOT AT ALL, 2= SLIGHTLY, 3= MODERATELY, 4= QUITE A BIT, 5= EXTREMELY
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?

1

2

3

4

5

1 is NOT AT ALL, 5 is EXTREMELY
1= NOT LIMITED AT ALL, 2= SLIGHTLY LIMITED, 3= MODERATELY LIMITED, 4= VERY LIMITED, 5= UNABLE
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?

1

2

3

4

5

1 is NOT LIMITED AT ALL, 5 is UNABLE
1= NONE, 2= MILD, 3= MODERATE, 4= SEVERE, 5=EXTREME
9. Arm, shoulder or hand pain.

1

2

3

4

5

1 is NONE, 5 is EXTREME
10. Tingling (pins and needles) in your arm, shoulder or hand.

1

2

3

4

5

1 is NONE, 5 is EXTREME
1= NO DIFFICULTY, 2= MILD DIFFICULTY, 3= MODERATE DIFFICULTY, 4= SEVERE DIFFICULTY, 5=SO MUCH DIFFICULTY THAT I CAN’T SLEEP
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number)

1

2

3

4

5

1 is NO DIFFICULTY, 5 is SO MUCH DIFFICULTY THAT I CAN’T SLEEP
QuickDASH DISABILITY/SYMPTOM SCORE
QuickDASH DISABILITY/SYMPTOM SCORE
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:
I do not work. (You may skip this section.)
Please select the number that best describes your physical ability in the past week.
1 = NO DIFFICULTY , 2 = MILD DIFFICULTY, 3 = MODERATE DIFFICULTY, 4 = SVERE DIFFICULTY, 5 = UNABLE

Score
Total Score Of This Module:
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:
I do not play a sport or an instrument. (You may skip this section.)
Please select the number that best describes your physical ability in the past week.

Score
Total Score Of This Module:
Should be Empty: