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Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.
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| | No difficulty | Mild difficulty | Moderate difficulty | Severe difficulty | Unable |
| 1. Open a tight or new jar. |
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| 2. Do heavy household chores (e.g., wash walls, floors). |
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| 3. Carry a shopping bag or briefcase. |
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| 4. Wash your back. |
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| 5. Use a knife to cut food. |
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| 6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.). |
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| Not at all | Slightly | Moderately | Quite a bit | Extremely |
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| 7. 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? |
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| Not limited at all | Slightly limited | Moderately limited | Very limited | Unable |
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| 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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Please rate the severity of the following symptoms in the last week.
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| None | Mild | Moderate | Severe | Extreme |
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| 9. Arm, shoulder or hand pain. |
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| 10. Tingling (pins and needles) in your arm, shoulder or hand. |
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| No difficulty | Mild difficulty | Moderate difficulty | Severe difficulty | So much difficulty that I can't sleep |
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| 11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? |
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