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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