The Disabilities of the Arm, Shoulder, and Hand Questionnaire

This questionnaire asks about your symptoms as well as your ability to perform certain activities. 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 response below the appropriate response. 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.

Full Name*
1. Open a tight or new jar
2. Write
3. Turn a key
4. Prepare a meal
5. Push open a heavy door
6. Place an object on a shelf above your head
7. Do heavy household chores (e.g., wash walls, wash floors)
8. Garden or do yard work
9. Make a bed
10. Carry a shopping bag or briefcase
11. Carry a heavy object (over 10 kg)
12. Change a lightbulb overhead
13. Wash or blow dry your hair
14. Wash your back
15. Put on a pullover sweater
16. Use a knife to cut food
17. Recreational activities which require little effort (e.g. card playing, knitting, etc.)
18. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g. golf, hammering, tennis, etc.)
19. Recreational activities in which you move your arm freely (e.g. playing frisbee, badminton, etc.)
20. Manage transportation needs (getting from one place to another)
21. Sexual activities
23. 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?
22. 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?
Please rate the severity of the following symptoms in the last week.
24. Arm, shoulder or hand pain
25.  Arm, shoulder or hand pain when you performed any specific activity
26. Tingling (pins and needles) in your arm, shoulder or hand
27.  Weakness in your arm, shoulder or hand
28.  Stiffness in your arm, shoulder or hand
29.  During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?
30.  I feel less capable, less confident or less useful because of my arm, shoulder or hand problem
Thank you
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