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| 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 |
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(e.g., cardplaying, knitting, etc.). | 1 | 2 | 3 | 4 | 5 | |
18. | Recreational activities in which you take some force |
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or impact through your arm, shoulder or hand |
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(e.g., golf, hammering, tennis, etc.). | 1 | 2 | 3 | 4 | 5 | |
19. | Recreational activities in which you move your |
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arm freely (e.g., playing frisbee, badminton, etc.). | 1 | 2 | 3 | 4 | 5 | |
20. | Manage transportation needs |
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(getting from one place to another). | 1 | 2 | 3 | 4 | 5 | |
21. | Sexual activities. | 1 | 2 | 3 | 4 | 5 |