|
| NO DIFFICULTY | MILD DIFFICULTY | MODERATE DIFFICULTY | SEVERE DIFFICULTY | UNABLE |
| 1) Open a tight or new jar | 0 | 1 | 2 | 3 | 4 |
| 2) Do heavy household chores (e.g., wash walls, and floors) | 0 | 1 | 2 | 3 | 4 |
| 3) Carry a shopping bag or briefcase | 0 | 1 | 2 | 3 | 4 |
| 4) Wash your back | 0 | 1 | 2 | 3 | 4 |
| 5) Use a knife to cut food | 0 | 1 | 2 | 3 | 4 |
| 6) Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.) | 0 | 1 | 2 | 3 | 4 |
| 7) During the past week, to what extent has your arm, shoulder, or hand problem interfered with your normal social activities with family, friends, neighbors, or groups? | NOT AT ALL 0 | SLIGHTLY 1 | MODERATELY 2 | QUITE A BIT 3 | EXTREMELY 4 |
| 8) During the past week, were you limited in your work or other regular daily activities due to your arm, shoulder, or hand problem? | NOT AT ALL 0 | SLIGHTLY LIMITED 1 | MODERATELY LIMITED 2 | VERY LIMITED 3 | UNABLE 4 |
| 9) Arm, shoulder, or hand pain | NONE 0 | MILD 1 | MODERATE 2 | SEVERE 3 | EXTREME 4 |