DASH Form

DASH

Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire

First Name(Required)

Last Name(Required)

Patient Date of Birth(Required)

Today's Date

Instructions: Please answer every question based on your condition in the last week. If you did not perform the activity in the past week, please estimate how difficult it would have been. Select only one response for each question.

1 = No Difficulty, 2 = Mild, 3 = Moderate, 4 = Severe, 5 = Unable

Physical Function / Symptoms
For each item, mark the column that best describes your difficulty in doing the activity in the last week:

1. Open a tight or new jar(Required)

2. Write(Required)

3. Turn a key(Required)

4. Prepare a meal(Required)

5. Push open a heavy door(Required)

6. Place an object on a shelf above your head(Required)

7. Do heavy household chores (wash walls, floors)(Required)

8. Garden or do yard work(Required)

9. Make a bed(Required)

10. Carry a shopping bag or briefcase(Required)

11. Change a lightbulb overhead(Required)

12. Wash or blow dry your hair(Required)

13. Wash your back(Required)

14. Put on a pullover sweater(Required)

15. Use a knife to cut food(Required)

16. Recreational activities requiring little effort (cards, knitting)(Required)

17. Recreational activities requiring force/impact (tennis, hammering)(Required)

18. Recreational activities requiring free arm movement (frisbee, badminton)(Required)

19. Manage transportation needs (driving, bus)(Required)

20. Sexual activities(Required)

21. Interference with normal social activities(Required)

22. Limitation in work or regular activities(Required)

23. Arm, shoulder or hand pain(Required)

24. Tingling in your arm, shoulder, or hand(Required)

25. Weakness in your arm, shoulder, or hand(Required)

26. Stiffness in your arm, shoulder, or hand(Required)

27. Difficulty sleeping due to arm, shoulder, or hand pain(Required)

28. Feeling less capable/confident/useful due to arm, shoulder, or hand problem(Required)

29. Severity of symptoms (none to extreme)(Required)

Optional Work Module
For People Who work outside the home

1. Work tasks requiring arm/hand use(Required)

2. Usual work duties(Required)

Optional Sports/Performing Arts Module
For people who play sports or perform arts

1. Sports/arts activities requiring arm strength(Required)

2. Sports/arts activities requiring free arm movement(Required)

Dr. Aaron Kovaleski, MD

Kendra Payne, FNP-BC

Kyle Odvody, MS, FNP-BC

Greg Charleston, AGACNP-BC

Arterial Disease

Women's Health

Men's Health

Joint Pain

Venous Issues

Liver Cancer

Non-Healing Wounds

Cosmetic

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