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

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4

5

6.

Place an object on a shelf above your head.

1

2

3

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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

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4

5

12.

Change a lightbulb overhead.

1

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4

5

13.

Wash or blow dry your hair.

1

2

3

4

5

14.

Wash your back.

1

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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

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5

20.

Manage transportation needs

(getting from one place to another).

1

2

3

4

5

21.

Sexual activities.

1

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4

5