PatientIQ Patient Portal

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 your ability regardless of how you perform the task.

Please rate your ability to do the following activities in the last week.

	No difficulty	Mild difficulty	Moderate difficulty	Severe difficulty	Unable
Open a tight or new jar
Do heavy household chores (eg wash walls, wash floors)
Carry a shopping bag or briefcase
Wash your back
Use a knife to cut food
Recreational activities in which you take some force or impact through your arm, shoulder or hand (eg golf, hammering, tennis, etc)

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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?

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

During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?

	None	Mild	Moderate	Severe	Extreme
Arm, shoulder or hand pain
Tingling (pins and needles) in your arm, shoulder or hand

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