• DISABILITIES OF THE ARM, SHOULDER AND HAND (DASH)

    Shoulder Pain Index Form
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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 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 your ability regardless of how you perform the task.

  • Please rate your ability to do the following activities in the last week by selecting the number for the appropriate response.

    1 = No Difficulty

    2 = Mild Difficulty

    3 = Moderate Difficulty

    4 = Severe Difficulty

    5 = Unable to Peform Task

     

  • Please rate your ability to open a tight or new jar*
  • Please rate your ability to write*
  • Please rate your ability to turn a key*
  • Please rate your ability to prepare a meal*
  • Please rate your ability to push open a heavy door*
  • Please rate your ability to place an object on a shelf above your head*
  • Please rate your ability to do heavy household chores (e.g. wash walls, wash floors)*
  • Please rate your ability to garden or do yard work*
  • Please rate your ability to make a bed*
  • Please rate your ability to carry a shopping bag or briefcase*
  • Please rate your ability to carry a heavy object (over 10lbs)*
  • Please rate your ability to change a lightbulb overhead*
  • Please rate your ability to wash or blow dry your hair*
  • Please rate your ability to wash your back*
  • Please rate your ability to put on a pullover sweater/sweatshirt*
  • Please rate your ability to use a knife to cut food*
  • Please rate your ability to perform recreational activities which require little effort (e.g. cardplaying, knitting, etc.)*
  • Please rate your ability to perform recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g. golf, hammering, tennis, etc.)*
  • Please rate your ability to perform recreational activities in which you move your arm freely (e.g. playing frisbee, badminton, etc.)*
  • Please rate your ability to manage transportation needs (getting from one place to another)*
  • Please rate your ability to sexual activities*
  • During the past week, to what extent has our arm, shoulder, or hand problem interfered with your normal social activities with family, friends, neighbors or groups?*
  • During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand?*
  • Please rate the severity of your symptoms in the last week: symptoms in your arm, shoulder or hand*
  • Please rate the severity of your symptoms in the last week: pain in your arm, shoulder or hand when you performed a specific activity*
  • Please rate the severity of your symptoms in the last week: tingling (pins and needles) in your arm, shoulder, or hand*
  • Please rate the severity of your symptoms in the last week: weakness in your arm, shoulder, or hand*
  • Please rate the severity of your symptoms in the last week: stiffness in your arm, shoulder, or hand*
  • During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?*
  • I feel less capable, less confident, or less useful because of my arm, shoulder, or hand problem.*

  • 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.

  • Do you work?
  • Please choose the option that best describes your physical ability in the past week. Did you have any difficulty using your usual technique for your work?
  • Please choose the option that best describes your physical ability in the past week. Did you have any difficulty doing your usual work because of arm, shoulder or hand pain?
  • Please choose the option that best describes your physical ability in the past week. Did you have any difficulty doing your work as well as you would like?
  • Please choose the option that best describes your physical ability in the past week. Did you have any difficulty spending your usual amount of time doing your work?

  • 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.

  • Do you play a sport (including exercise) or musical instrument?
  • Please select the option that best describes your physical ability in the past week. Did you have any difficulty: using your usual technique for playing your sport or instrument?
  • Please select the option that best describes your physical ability in the past week. Did you have any difficulty: playing your musical instrument or sport because of arm, shoulder, or hand pain?
  • Please select the option that best describes your physical ability in the past week. Did you have any difficulty: playing your musical instrument or sport as well as you would like?
  • Please select the option that best describes your physical ability in the past week. Did you have any difficulty: spending your usual amount of time practicing or playing your instrument or sport?

  • Neck Index

  • Shoulder pain is very closely related to the neck (cervical spine). This questionaire will give your provider information about how your neck condition affects your shoulder and everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one that most closely describes your pain.

  • Pain Intensity*
  • Sleeping*
  • Reading*
  • Concentration*
  • Work*
  • Personal Care*
  • Lifting*
  • Driving*
  • Recreation*
  • Headaches*
  • Should be Empty: