PHYSICAL THERAPY  WELLNESS SERVICES  PAIN MANAGEMENT  SPORTS ENHANCEMENT

The QuickDASH Outcome Measures

INSTRUCTIONS

This questionnaire asks about your symptoms as

well as your ability to perform certain activities.

Please answer every question, based on your

condition in the last week, by checking the
appropriate response.

If you did not have the opportunity to perform an

activity in the past week, please make your best
estimate of which response would be most
accurate.

It doesn't matter which hand or arm you use to

perform the activity; please answer based on your
ability regardless of how you perform the task.

This questionnaire is designed to accommodate

multiple evaluations, please only fill out the row
for the evaluation date you are completing.
 PHYSICAL THERAPY  WELLNESS SERVICES  PAIN MANAGEMENT  SPORTS ENHANCEMENT

QuickDASH

Section 1: To be completed by patient

Name: ___________________________________ Age: _______ AD Non-Active Duty
Occupation: ______________________________ Number of days of in pain: _______ (this episode)

Initial Date Follow-up Date Follow-up Date Discharge/Follow-up Date

Section 2: To be completed by patient

Please rate your ability to do the following activities in the last week by checking the appropriate response.
Please only check boxes in the column for the evaluation date you are entering and only check one box per category.
Reset Column Reset Column Reset Column Reset Column
Initial Evaluation Follow-up Follow-up Discharge

1. Open a jar.
No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

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

No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

3. Carry a shopping bag or briefcase.

No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

4. Wash your back.

No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

5. Use a knife to cut food.

No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.)
No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5
 PHYSICAL THERAPY  WELLNESS SERVICES  PAIN MANAGEMENT  SPORTS ENHANCEMENT

QuickDASH, p.2

Section 2 (Con’t): To be completed by patient

Please rate your ability to do the following activities in the last week by checking the appropriate response.
Please only check boxes in the column for the evaluation date you are entering and only check one box per category.

Initial Evaluation Follow-up Follow-up Discharge

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?
Not at all = 1
Slightly = 2
Moderately = 3
Quite a bit = 4
Extremely = 5

8. During the past week, were you limited in your work on other regular daily activities as a result of your arm, shoulder or hand problem?
Not limited at all = 1
Slightly limited = 2
Moderately limited = 3
Very limited = 4
Unable = 5

Please rate the severity of the following symptoms in the last week.
9. Arm, shoulder or hand pain.
None = 1
Mild = 2
Moderate = 3
Severe = 4
Extreme = 5

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

None = 1
Mild = 2
Moderate = 3
Severe = 4
Extreme = 5

11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?
No difficulty = 1
Mild difficulty = 2
Moderate difficulty = 3
Severe difficulty = 4
So much difficulty that I can't sleep = 5

TOTAL SCORE
Total
Divided by number of questions
Subtract 1
Times 25 TOTAL SCORE

(𝑠𝑢𝑚 𝑜𝑓 𝑛 𝑟𝑒𝑠𝑝𝑜𝑛𝑠𝑒𝑠) −1
QuickDASH DISABILITY/SYMPTOM SCORE = �� � � 𝑥 25, where n is equal to the number of completed responses.
𝑛
A QuickDASH score may not be calculated if there is greater than 1 missing item.
 PHYSICAL THERAPY  WELLNESS SERVICES  PAIN MANAGEMENT  SPORTS ENHANCEMENT

QuickDASH, p.3

Section 3 - WORK MODULE (OPTIONAL): To be completed by patient

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking if that is your
main work role).

Please indicate what your job/work is: ___________________________________________________________________________

I do not work. (You may skip this section.)

Please check the response that best describes your physical ability in the past week.
Please only check boxes in the column for the evaluation date you are entering and only check one box per category.
Reset Column Reset Column Reset Column Reset Column
Initial Evaluation Follow-up Follow-up Discharge

1. Using your usual technique for your work?

No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

2. Doing your usual work because of arm, shoulder or hand pain?

No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

3. Doing your work as well as you would like?

No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

4. Spending your usual amount of time doing your work?

No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

TOTAL SCORE
Total
Divided by number of questions
Subtract 1
Times 25 TOTAL SCORE

(𝑠𝑢𝑚 𝑜𝑓 𝑛 𝑟𝑒𝑠𝑝𝑜𝑛𝑠𝑒𝑠) −1
SCORING THE OPTIONAL MODULES = �� � � 𝑥 25, where n is equal to the number of completed responses.
𝑛
An optional module score may not be calculated if there is greater than 1 missing item.
 PHYSICAL THERAPY  WELLNESS SERVICES  PAIN MANAGEMENT  SPORTS ENHANCEMENT

QuickDASH, p.4

Section 4 - SPORTS/PERFORMING ARTS MODULE (OPTIONAL): To be completed by patient

The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or both. If you
play more than one sport or instrument (or play both), pleas answer with respect to that activity which is most important to you.

Please indicate the sport or instrument which is most important to you: _______________________________________________

I do not play a sport or an instrument. (You may skip this section.)

Please check the response that best describes your physical ability in the past week.
Please only check boxes in the column for the evaluation date you are entering and only check one box per category.
Reset Column Reset Column Reset Column Reset Column
Initial Evaluation Follow-up Follow-up Discharge

1. Using your usual technique for playing your instrument or sport?

No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

2. Playing your musical instrument or sport because of arm, shoulder or hand pain?
No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

3. Playing your musical instrument or sport as well as you would like?

No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

4. Spending your usual amount of time practicing or playing your instrument or sport?
No Difficulty = 1
Mild Difficulty = 2
Moderate Difficulty = 3
Severe Difficulty = 4
Unable = 5

TOTAL SCORE
Total
Divided by number of questions
Subtract 1
Times 25 TOTAL SCORE

(𝑠𝑢𝑚 𝑜𝑓 𝑛 𝑟𝑒𝑠𝑝𝑜𝑛𝑠𝑒𝑠) −1
SCORING THE OPTIONAL MODULES = �� � � 𝑥 25, where n is equal to the number of completed responses.
𝑛
An optional module score may not be calculated if there is greater than 1 missing item.
 PHYSICAL THERAPY  WELLNESS SERVICES  PAIN MANAGEMENT  SPORTS ENHANCEMENT

QuickDASH, p.5

Section 5: To be completed by physical therapist/provider

QuickDASH SCORE: Initial _____ Follow-up _____ Follow-up _____ Discharge/Follow-up _____
Work Module SCORE: Initial _____ Follow-up _____ Follow-up _____ Discharge/Follow-up _____
Sports Module SCORE: Initial _____ Follow-up _____ Follow-up _____ Discharge/Follow-up _____

TOTAL DISABILITY SCORE: _____

0.00 _____
0.00 _____
0.00 _____
0.00

Number of Treatment Sessions: _____________________

Diagnosis/ICD-9 Code: _____________________________