Brookline 617-860-6430 Drydock 617-608-3695 Acton 617-860-6426

Disabilities of the Arms, Shoulder and Hands Form


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

MM slash DD slash YYYY
Open a tight or new jar.
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?
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 / n) - 1] x 25, where n is the number of completed responses. )

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

MM slash DD slash YYYY
0 = no pain and 10 = worst pain
0 = no pain and 10 = worst pain
How often do you experience your symptoms?(Required)
How much have your symptoms interfered with your usual daily activities?(Required)
(including both work outside the home and housework)
How is your condition changing, since care began at this facility?(Required)
In general, would you say your overall health right now is...(Required)
Signer's Name(Required)

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