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Home » Patient Info » Patient Forms » Disabilities of Arm Shoulder Hand Score (DASH)

Disabilities of Arm Shoulder Hand Score (DASH)

Today's date

The Disabilities of the Arm, Shoulder and Hand (DASH) Score

Clinician's name (or ref) :

Patient's name (or ref)

Patient's Date of Birth :

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. 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 you ability regardless of how you perform the task.

Please rate your ability to do the following activities in the last week.
1.	Open a tight or new jar
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
2.	Write
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
3.	Turn a key
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
4.	Prepare a meal
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
5.	Push open a heavy door
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
6.	Place an object on a shelf above your head
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
7. Do heavy household chores (eg wash walls, wash floors)
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
8.	Garden or do yard work
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
9.	Make a bed
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
10.	Carry a shopping bag or briefcase
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
11.	Carry a heavy object (over 10 lbs)
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
12.	Change a lightbulb overhead
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
13.	Wash or blow dry your hair
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty		Unable
14.	Wash your back
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
15.	Put on a pullover sweater
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
16.	Use a knife to cut food
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
17.	Recreational activities which require little effort (eg cardplaying, knitting, etc)
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
18.	Recreational activities in which you take some force or impact through your arm, shoulder or hand (eg golf, hammering, tennis, etc)
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
19.	Recreational activities in which you move your arm freely (eg playing frisbee, badminton, etc)
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
20.	Manage transportation needs (getting from one place to another)
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
21.	Sexual activities
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	Unable
22.	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
23.	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
24.	Arm, shoulder or hand pain
	None		Mild	Moderate	Severe	Extreme
25.	Arm, shoulder or hand pain when you performed any specific activity
	None		Mild	Moderate	Severe	Extreme
26.	Tingling (pins and needles) in your arm, shoulder or hand
	None		Mild	Moderate	Severe	Extreme
27.	Weakness in your arm, shoulder or hand
	None		Mild	Moderate	Severe	Extreme
27.	Stiffness in your arm, shoulder or hand
	None		Mild	Moderate	Severe	Extreme
29.	During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?
	No difficulty		Mild difficulty	Moderate difficulty	Severe difficulty	So much I can't sleep
30.	I feel less capable, less confident or less useful because of my arm, shoulder or hand problem
	Strongly disagree		Disagree	Neither agree nor disagree	Agree	Strongly agree

The Disabilies of the Arm, Shoulder and Hand (DASH) Score is		To send this data to doctor please click submit