Upper Extremity (Shoulder – Elbow – Wrist) Pain and ...



UPPER EXTREMITY (SHOULDER – ELBOW – WRIST)

PAIN AND DISABILITY QUESTIONNAIRE

Name: ___________________ Date: ____________________

Please place a number on the line to show your PAIN level for each question.

No Pain 0__ 1__ 2__ 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10 Worst Pain Imaginable

1. At its worst? ______

2. When lying on the involved side? ______

3. When reaching for something on a high shelf? ______

4. Carrying a heavy object of 10 pounds or more? ______

5. When pushing with the involved arm? ______

Please place a number to show how much DIFFICULTY you have for each question.

No Difficulty 0__ 1__ 2__ 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10 Unable to do

1. Washing your hair? _____

2. Washing your back? _____

3. Putting on an undershirt or pullover shirt? ______

4. Putting on a shirt that buttons down from the front? ______

5. Putting on your pants? ______

6. Removing something from your back pocket? ______

7. Brushing your teeth? ______

8. Holding a mug/plate? ______

9. Writing? ______

State the chief problem you are having today? __________________________________

________________________________________________________________________

Do you take any pain medications? (If yes, please write them below)

________________________________________________________________________

On a scale of 0 to 10 (0 being the best, 10 being the worst) how would you rate your level of pain today? _________

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