Upper Extremity Functional Scale

Please fill out the following scale form as accurately as possible and upload with your new client form. If you would prefer to download the PDF of this form, please click the button below and upload it on our New Client Form page.

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Intructions

This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer every question, based on your condition in the last week, by circling the appropriate number. If you did not have the opportunity to perform an activity in the past week, please make your best estimate of which response would be the most accurate. It doesn’t matter which hand or arm you use to perform the activity; please answer based on your ability regardless of how you perform the task.

Please rate your pain level with activity:

Selected Value: 0

0 = NO PAIN, 10 = VERY SEVERE PAIN

	NO DIFFICULTY	MILD DIFFICULTY	MODERATE DIFFICULTY	SEVERE DIFFICULTY	UNABLE
Open a tight or new jar	NO DIFFICULTYOpen a tight or new jar NO DIFFICULTY	MILD DIFFICULTYOpen a tight or new jar MILD DIFFICULTY	MODERATE DIFFICULTYOpen a tight or new jar MODERATE DIFFICULTY	SEVERE DIFFICULTYOpen a tight or new jar SEVERE DIFFICULTY	UNABLEOpen a tight or new jar UNABLE
Do heavy household chores (e.g. wash walls, floors)	NO DIFFICULTYDo heavy household chores (e.g. wash walls, floors) NO DIFFICULTY	MILD DIFFICULTYDo heavy household chores (e.g. wash walls, floors) MILD DIFFICULTY	MODERATE DIFFICULTYDo heavy household chores (e.g. wash walls, floors) MODERATE DIFFICULTY	SEVERE DIFFICULTYDo heavy household chores (e.g. wash walls, floors) SEVERE DIFFICULTY	UNABLEDo heavy household chores (e.g. wash walls, floors) UNABLE
Carry a shopping back or briefcase	NO DIFFICULTYCarry a shopping back or briefcase NO DIFFICULTY	MILD DIFFICULTYCarry a shopping back or briefcase MILD DIFFICULTY	MODERATE DIFFICULTYCarry a shopping back or briefcase MODERATE DIFFICULTY	SEVERE DIFFICULTYCarry a shopping back or briefcase SEVERE DIFFICULTY	UNABLECarry a shopping back or briefcase UNABLE
Wash your back	NO DIFFICULTYWash your back NO DIFFICULTY	MILD DIFFICULTYWash your back MILD DIFFICULTY	MODERATE DIFFICULTYWash your back MODERATE DIFFICULTY	SEVERE DIFFICULTYWash your back SEVERE DIFFICULTY	UNABLEWash your back UNABLE
Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.)	NO DIFFICULTYRecreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.) NO DIFFICULTY	MILD DIFFICULTYRecreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.) MILD DIFFICULTY	MODERATE DIFFICULTYRecreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.) MODERATE DIFFICULTY	SEVERE DIFFICULTYRecreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.) SEVERE DIFFICULTY	UNABLERecreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.) UNABLE

	NOT AT ALL	SLIGHTLY	MODERATELY	QUITE A BIT	EXTREMELY
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 ALLDuring 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	SLIGHTLYDuring 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? SLIGHTLY	MODERATELYDuring 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? MODERATELY	QUITE A BITDuring 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? QUITE A BIT	EXTREMELYDuring 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? EXTREMELY

	NOT LIMITED AT ALL	SLIGHTLY LIMITED	MODERATELY LIMITED	VERY LIMITED	EXTREMELY
During the past week, were you limited in your work or regular daily activities as a result of your arm, shoulder, or hand problems?	NOT LIMITED AT ALLDuring the past week, were you limited in your work or regular daily activities as a result of your arm, shoulder, or hand problems? NOT LIMITED AT ALL	SLIGHTLY LIMITEDDuring the past week, were you limited in your work or regular daily activities as a result of your arm, shoulder, or hand problems? SLIGHTLY LIMITED	MODERATELY LIMITEDDuring the past week, were you limited in your work or regular daily activities as a result of your arm, shoulder, or hand problems? MODERATELY LIMITED	VERY LIMITEDDuring the past week, were you limited in your work or regular daily activities as a result of your arm, shoulder, or hand problems? VERY LIMITED	EXTREMELYDuring the past week, were you limited in your work or regular daily activities as a result of your arm, shoulder, or hand problems? EXTREMELY

Please rate the severity of the following symptoms in the last week.

	NONE	MILD	MODERATE	SEVERE	EXTREME
Arm, shoulder, or hand pain	NONEArm, shoulder, or hand pain NONE	MILDArm, shoulder, or hand pain MILD	MODERATEArm, shoulder, or hand pain MODERATE	SEVEREArm, shoulder, or hand pain SEVERE	EXTREMEArm, shoulder, or hand pain EXTREME
Tingling (pins and needles) in your arm, shoulder, or hand	NONETingling (pins and needles) in your arm, shoulder, or hand NONE	MILDTingling (pins and needles) in your arm, shoulder, or hand MILD	MODERATETingling (pins and needles) in your arm, shoulder, or hand MODERATE	SEVERETingling (pins and needles) in your arm, shoulder, or hand SEVERE	EXTREMETingling (pins and needles) in your arm, shoulder, or hand EXTREME

	NONE	MILD	MODERATE	SEVERE DIFFICULTY	SO MUCH DIFFICULTY THAT I CAN'T SLEEP
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand?	NONEDuring the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? NONE	MILDDuring the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? MILD	MODERATEDuring the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? MODERATE	SEVERE DIFFICULTYDuring the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? SEVERE DIFFICULTY	SO MUCH DIFFICULTY THAT I CAN'T SLEEPDuring the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? SO MUCH DIFFICULTY THAT I CAN'T SLEEP

Upper Extremity Functional Scale

Intructions

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