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.

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.
Selected Value: 0
0 = NO PAIN, 10 = VERY SEVERE PAIN
NO DIFFICULTYMILD DIFFICULTYMODERATE DIFFICULTYSEVERE DIFFICULTYUNABLE
Open a tight or new jar
Do heavy household chores (e.g. wash walls, floors)
Carry a shopping back or briefcase
Wash your back
Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.)
NOT AT ALLSLIGHTLYMODERATELYQUITE A BITEXTREMELY
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 LIMITED AT ALLSLIGHTLY LIMITEDMODERATELY LIMITEDVERY LIMITEDEXTREMELY
During the past week, were you limited in your work or regular daily activities as a result of your arm, shoulder, or hand problems?
NONEMILDMODERATESEVEREEXTREME
Arm, shoulder, or hand pain
Tingling (pins and needles) in your arm, shoulder, or hand
NONEMILDMODERATESEVERE DIFFICULTYSO 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?
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