Shoulder and Elbow Disability Questionaire

Patient Name*

First Middle Last

Date of Birth*

Physician*

Please rate your ability to perform the following activities in the past week:

Open a tight or new jar*

No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable to Perform

Do heavy household chores (e.g. wash walls, wash floors, etc.)*

No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable to Perform

Carry a shopping bag or briefcase*

No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable to Perform

Wash your back*

No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable to Perform

Use utensils to eat food*

No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable to Perform

Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc.)*

No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable to Perform

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

Not limited at all
Slightly limited
Moderately limited
Very limited
Unable to perform

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

Pain in your arm, shoulder, or hand*

Tingling (pins and needles) in your arm, shoulder, or hand*

No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable to Perform

Difficulty sleeping because of pain in your arm, shoulder, or hand*

No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable to Perform

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