NOT AT ALL

SLIGHTLY

MODERATELY

QUITE

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

UNABLE

AT ALL

LIMITED

LIMITED

LIMITED

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

NO

DIFFICULTY

MILD

DIFFICULTY

MODERATE

DIFFICULTY

SEVERE

DIFFICULTY

SO MUCH

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

DISAGREE

NEITHER AGREE

NOR DISAGREE

AGREE

STRONGLY

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