Fiona Stanley Fremantle Hospitals Group

General

Please rate your ability to do the following activities in the last week by selecting appropriate response below.Open a tight or new jar. No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Do heavy household chores (e.g. wash walls, floors). No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Carry a shopping bag or briefcase. No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Wash your back. No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Use a knife to cut food. No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g. golf, hammering, tennis, etc.). No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable 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 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 Arm, shoulder or hand pain. Please rate the severity of the following symptoms in the last week. None Mild Moderate Severe Extreme Tingling (pins and needles) in your arm, shoulder or hand. Please rate the severity of the following symptoms in the last week. None Mild Moderate Severe Extreme 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 that I cannot sleep

Work Module

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).

I do not work

Please indicate what your job / work is: Do you have any difficulty using your usual technique for your work? No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Do you have any difficulty doing your usual work because of arm, shoulder or hand pain? No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Do you have any difficulty doing your work as well as you would like? No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Do you have any difficulty spending your usual amount of time doing your work? No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable

Sports / Performing Arts Module

The following questions relate to the impact of your arm, shoulder or hand problem on playingyour 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.

I do not play a sport or an instrument.

Please indicate the sport or instrument which is most important to you: Did you have any difficulty using your usual technique for playing your instrument or sport? No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Did you have any difficulty playing your musical instrument or sport because of arm, shoulder or hand pain? No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Did you have any difficulty playing your musical instrument or sport as well as you would like? No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable Did you have any difficulty spending your usual amount of time practising or playing your instrument or sport? No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable

BIMS QuickDASH

All questions must be answered before the survey can be submitted. Your survey will be saved automatically when you have finished.

General

Work Module

Sports / Performing Arts Module