Dash Questionnaire

Family Physical Therapy and Wellness > Dash Questionnaire

FPT Dash Questionaire

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

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NO DIFFICULTY | MILD DIFFICULTY | MODERATE DIFFICULTY | SEVERE DIFFICULTY | UNABLE

1. open tight or new jar

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5

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

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5

3. Carry a shopping bag or briefcase.

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5

4. Wash your back.

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5

5. Use a knife to cut food

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5

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

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5

7. 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?

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EXTREME

NOT LIMITED AT ALL | SLIGHTLY LIMITED | MODERATELY LIMITED | VERY LIMITED | UNABLE

8. 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?

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5

Please rate the severity of the following symptoms in the last week. (circle number)

NONE | MILD | MODERATE | SEVERE | EXTREME

9. Arm, shoulder or hand pain.

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5

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

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5

11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number)

1
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5

Family Physical Therapy is a therapist-owned clinic located in Oaklon, VAand is in network with most major insurance companies

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7501 Little River Turnpike, Suite 306, Annandale, VA 22003
(703)261-6005
pazokidpt@familyptwellness.com

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