Disabilities Of The Arm, Shoulder and Hand (DASH)

First Name(Required)

Last Name(Required)

Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.

	No Difficulty – 1	Mild Difficulty – 2	Moderate Difficulty – 3	Severe Difficulty – 4	Unable – 5
Open a tight or new jar
Write
Turn a key
Prepare a meal
Push open a heavy door
Place an object on a shelf above your head
Do heavy household chores (e.g., wash walls, wash floors)
Garden or do yard work
Make a bed
Carry a shopping bag or briefcase
Carry a heavy object (over 10 lbs)
Change a lightbulb overhead
Wash or blow dry your hair
Wash your back
Put on a pullover sweater
Use a knife to cut food
Recreational activities which require little effort (e.g., cardplaying, knitting, etc.)
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 move your arm freely (e.g., playing frisbee, badminton, etc.)
Manage transportation needs (getting from one place to another)
Sexual activities

During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours or groups?

During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem?

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

	None – 1	Mild – 2	Moderate – 3	Severe – 4	Extreme – 5
Arm, shoulder or hand pain
Arm, shoulder or hand pain when you performed any specific activity
Tingling (pins and needles) in your arm, shoulder or hand
Weakness in your arm, shoulder or hand
Stiffness 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?

I feel less capable, less confident or less useful because of my arm, shoulder or hand problem.

DASH DISABILITY/SYMPTOM SCORE = (((sum of n responses) – 1) x 25)/n, where n is equal to the number of completed responses.

A DASH score may not be calculated if there are greater than 3 missing items.

Work Module (optional)

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking if that is your main work role).

Employment Status(Required)

I work

I do not work

Please indicate what your job/work is

Please circle the number that best describes your physical ability in the past week. Did you have any difficulty:

	No Difficulty – 1	Mild Difficulty – 2	Moderate Difficulty – 3	Severe Difficulty – 4	Unable – 5
Using your usual technique for your work?
Doing your usual work because of arm, shoulder or hand pain?
Doing your work as well as you would like?
Spending your usual amount of time doing your work?

Sports/Performing Arts Module (option)

The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which is most important to you.

Sports/Performaning Arts Status(Required)

I play a sport or instrument

I do not play a sport or instrument

Please indicate the sport or instrument which is most important to you:

Please circle the number that best describes your physical ability in the past week. Did you have any difficulty:

	No Difficulty – 1	Mild Difficulty – 2	Moderate Difficulty – 3	Severe Difficulty – 4	Unable – 5
Using your usual technique for playing your instrument or sport?
Playing your musical instrument or sport because of arm, shoulder or hand pain?
Playing your musical instrument or sport as well as you would like?
Spending your usual amount of time practising or playing your instrument or sport?

SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by 4 (number of items); subtract 1; multiply by 25.

An optional module score may not be calculated if there are any missing items.