| 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 |