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	Open a tight or new jar NO DIFFICULTY	Open a tight or new jar MILD DIFFICULTY	Open a tight or new jar MODERATE DIFFICULTY	Open a tight or new jar SEVERE DIFFICULTY	Open a tight or new jar UNABLE
Do heavy household chores (e.g. wash walls, floors)	Do heavy household chores (e.g. wash walls, floors) NO DIFFICULTY	Do heavy household chores (e.g. wash walls, floors) MILD DIFFICULTY	Do heavy household chores (e.g. wash walls, floors) MODERATE DIFFICULTY	Do heavy household chores (e.g. wash walls, floors) SEVERE DIFFICULTY	Do heavy household chores (e.g. wash walls, floors) UNABLE
Carry a shopping back or briefcase	Carry a shopping back or briefcase NO DIFFICULTY	Carry a shopping back or briefcase MILD DIFFICULTY	Carry a shopping back or briefcase MODERATE DIFFICULTY	Carry a shopping back or briefcase SEVERE DIFFICULTY	Carry a shopping back or briefcase UNABLE
Wash your back	Wash your back NO DIFFICULTY	Wash your back MILD DIFFICULTY	Wash your back MODERATE DIFFICULTY	Wash your back SEVERE DIFFICULTY	Wash 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.)	Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.) NO DIFFICULTY	Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.) MILD DIFFICULTY	Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.) MODERATE DIFFICULTY	Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.) SEVERE DIFFICULTY	Recreational 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?	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	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? SLIGHTLY	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? MODERATELY	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? QUITE A BIT	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? 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?	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 ALL	During 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	During 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	During 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	During 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	Arm, shoulder, or hand pain NONE	Arm, shoulder, or hand pain MILD	Arm, shoulder, or hand pain MODERATE	Arm, shoulder, or hand pain SEVERE	Arm, shoulder, or hand pain EXTREME
Tingling (pins and needles) in your arm, shoulder, or hand	Tingling (pins and needles) in your arm, shoulder, or hand NONE	Tingling (pins and needles) in your arm, shoulder, or hand MILD	Tingling (pins and needles) in your arm, shoulder, or hand MODERATE	Tingling (pins and needles) in your arm, shoulder, or hand SEVERE	Tingling (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?	During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? NONE	During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? MILD	During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? MODERATE	During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? SEVERE DIFFICULTY	During 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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