Quick DASH Form | Merivale Hand Clinic

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 of 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.

"*" indicates required fields

* Required fields

Your details

Name*

First Last

DOB*

Questionnaire

Please rate your ability to do the following activities in the last week by selecting the appropriate option.

1. Open a tight or new jar.*

2. Do heavy household chores (e.g., wash walls, floors).*

3. Carry a shopping bag or briefcase.*

4. Wash your back.*

5. Use a knife to cut food.*

6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).*

7. 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?*

8. 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.

9. Arm, shoulder or hand pain.*

10. Tingling (pins and needles) in your arm, shoulder or hand.*

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

Work modual (Optional)

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including home making if that is your main work role).

Please indicate what your job/work is:

Please choose the option that best describes your physical ability in the past week. Please complete all fields.

1. using your usual technique for your work?

2. doing your usual work because of arm, shoulder or hand pain?

3. doing your work as well as you would like?

4. spending your usual amount of time doing your work?

Sports or 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.

Please indicate the sport or instrument which is most important to you:

Please select the option that best describes your physical ability in the past week. Did you have any difficulty performing the following tasks?

1. using your usual technique for playing your instrument or sport?

2. playing your musical instrument or sport because of arm, shoulder or hand pain?

3. playing your musical instrument or sport as well as you would like?

4. spending your usual amount of time practising or playing your instrument or sport?

Your personal information will only be used to service your enquiry. We will only contact you with relevant information. For further information view our full Privacy Policy.

Phone

This field is for validation purposes and should be left unchanged.

Rehabilitation of the Hand, Wrist And Elbow

Our Hand Clinics

We have clinics in Merivale, Papanui, Moorhouse Ave, Halswell and Kaiapoi

contact us

Contact Us

Your details

Questionnaire

Work modual (Optional)

Sports or Performing arts module (Optional)

Rehabilitation of the Hand, Wrist And Elbow

Our Hand Clinics

Merivale Hand Clinic

Our Affiliations

What we do

About Us

Quick Links

CONTACT US