D ISABILITIES OF THE A RM , S HOULDER AND H AND

Name:______________________________________ Date:___________________ DOB:_________________

Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.

Total Dash Score: ______________ NO MILD MODERATE SEVERE

UNABLE
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY

1. Open a tight or new jar. 1 2 3 4 5

2. Write. 1 2 3 4 5

3. Turn a key. 1 2 3 4 5

4. Prepare a meal. 1 2 3 4 5

5. Push open a heavy door. 1 2 3 4 5

6. Place an object on a shelf above your head. 1 2 3 4 5

7. Do heavy household chores (e.g., wash walls, wash floors). 1 2 3 4 5

8. Garden or do yard work. 1 2 3 4 5

9. Make a bed. 1 2 3 4 5

10. Carry a shopping bag or briefcase. 1 2 3 4 5

11. Carry a heavy object (over 10 lbs). 1 2 3 4 5

12. Change a lightbulb overhead. 1 2 3 4 5

13. Wash or blow dry your hair. 1 2 3 4 5

14. Wash your back. 1 2 3 4 5

15. Put on a pullover sweater. 1 2 3 4 5

16. Use a knife to cut food. 1 2 3 4 5

17. Recreational activities which require little effort

(e.g., cardplaying, knitting, etc.). 1 2 3 4 5

18. Recreational activities in which you take some force

or impact through your arm, shoulder or hand
(e.g., golf, hammering, tennis, etc.). 1 2 3 4 5

19. Recreational activities in which you move your

arm freely (e.g., playing frisbee, badminton, etc.). 1 2 3 4 5

20. Manage transportation needs

(getting from one place to another). 1 2 3 4 5

21. Sexual activities. 1 2 3 4 5

 D ISABILITIES OF THE A RM , S HOULDER AND H AND

Name:_________________________ Date:____________________ DOB:______________________

QUITE
NOT AT ALL SLIGHTLY MODERATELY EXTREMELY
A BIT

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?
(circle number) 1 2 3 4 5

NOT LIMITED SLIGHTLY MODERATELY VERY

AT ALL LIMITED LIMITED LIMITED UNABLE

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? (circle number) 1 2 3 4 5

Please rate the severity of the following symptoms in the last week. (circle number)

NONE MILD MODERATE SEVERE EXTREME

24. Arm, shoulder or hand pain. 1 2 3 4 5

25. Arm, shoulder or hand pain when you

performed any specific activity. 1 2 3 4 5

26. Tingling (pins and needles) in your arm, shoulder or hand. 1 2 3 4 5

27. Weakness in your arm, shoulder or hand. 1 2 3 4 5

28. Stiffness in your arm, shoulder or hand. 1 2 3 4 5

SO MUCH
NO MILD MODERATE SEVERE DIFFICULTY
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY THAT I
CAN’T SLEEP

29. During the past week, how much difficulty have you had
sleeping because of the pain in your arm, shoulder or hand?
(circle number) 1 2 3 4 5

STRONGLY DISAGREE NEITHER AGREE AGREE STRONGLY

DISAGREE NOR DISAGREE AGREE

30. I feel less capable, less confident or less useful

because of my arm, shoulder or hand problem.
(circle number) 1 2 3 4 5

DASH DISABILITY/SYMPTOM SCORE = ( [(sum of n responses / n) - 1] x 25, where n is the number of completed responses. )

A DASH score may not be calculated if there are greater than 3 missing items.