The Disabilities of the Arm Shoulder and Hand (DASH) Symptom Scale
|
|
|
- Lesley McCormick
- 7 years ago
- Views:
Transcription
1 The Disabilities of the Arm Shoulder and Hand (DASH) Symptom Scale Overview: The Disabilities of the Arm Shoulder and Hand (DASH) symptom scale can be used to evaluate a patient with a disorder of the upper extremity. It can be used to monitor the patient over time and to determine the effectiveness of an intervention. Measures: (1) opening a tight or new jar (2) writing (3) turning a key (4) preparing a meal (5) pushing open a heavy door (6) placing an object on a shelf above the head (7) doing heavy household chores (8) gardening or doing yard work (9) making a bed (10) carrying a shopping bag or briefcase (11) carrying a heavy object (over 5 kilograms) (12) changing a light bulb overhead (13) washing or blowing drying the hair (14) washing the back (15) putting on a pullover sweater (16) using a knife to cut food (17) recreational activities that require little effort (18) recreational activities that require taking some force or impact through the arm shoulder or hand (19) recreational activities that require moving the arm freely (20) managing transportation needs (getting from one place to another) (21) sexual activities (22) social activities (23) work and other daily activities
2 (24) pain (25) pain when performing activities (26) tingling (27) weakness (28) stiffness (29) difficulty in sleeping (30) impact on self-image Response Points no difficulty or no symptom 0 slight difficulty or mild symptom 1 moderate difficulty or symptom 2 severe difficulty or symptom 3 unable to perform or very severe symptom 4 where: Pain (item 24) may refer to pain at rest. Alternatively the points may be assigned from 1 to 5. total score = SUM(points for all 30 items) adjusted score (if scored from 0 to 4) = (total score for patient) / 120 * 100 Interpretation: minimum score (using 0 to 4 scale): 0 maximum score (using 0 to 4 sacle): 120 minimum adjusted score: 0 maximum adjusted score: 100 Adjusted Score Disability Level 0 no disability 100 extreme disability References:
3 Atroshi I Gummesson C et al. The disabilities of the arm shoulder and hand (DASH) outcome queestionnaire. Reliability and validity of the Swedish version evaluated in 176 patients. Acta Orthop Scand. 2000; 71: (Table 1 page 614). Hudak PL Amadio PC Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm shoulder and hand). Am J Indust Med. 1996; 29:
4 DISABILITIES OF THE ARM, SHOULDER AND HAND THE DASH 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 circling the appropriate number. If you did not have the opportunity to perform an activity in the past week, please make your best estimate on which response would be the 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.
5 DISABILITIES OF THE ARM, SHOULDER AND HAND Please rate your ability to do the following activities in the last week by circling the number below the appropriate response. 1. Open a tight or new jar. 2. Write. 3. Turn a key. 4. Prepare a meal. 5. Push open a heavy door. 6. Place an object on a shelf above your head. 7. Do heavy household chores (e.g., wash walls, wash floors). 8. Garden or do yard work. 9. Make a bed. 10. Carry a shopping bag or briefcase. 11. Carry a heavy object (over 10 lbs). 12. Change a lightbulb overhead. 13. Wash or blow dry your hair. 14. Wash your back. 15. Put on a pullover sweater. 16. Use a knife to cut food. 17. Recreational activities which require little effort (e.g., cardplaying, knitting, etc.). 18. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.). 19. Recreational activities in which you move your arm freely (e.g., playing frisbee, badminton, etc.). 20. Manage transportation needs (getting from one place to another). 21. Sexual activities.
6 DISABILITIES OF THE ARM, SHOULDER AND HAND NOT AT ALL SLIGHTLY MODERATELY QUITE A BIT EXTREMELY 22. 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? (circle number) NOT LIMITED SLIGHTLY MODERATELY VERY AT ALL LIMITED LIMITED LIMITED 23. 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? (circle number) Please rate the severity of the following symptoms in the last week. (circle number) NONE MILD MODERATE SEVERE EXTREME 24. Arm, shoulder or hand pain. 25. Arm, shoulder or hand pain when you performed any specific activity. 26. Tingling (pins and needles) in your arm, shoulder or hand. 27. Weakness in your arm, shoulder or hand. 28. Stiffness in your arm, shoulder or hand. SO MUCH DIFFICULTY THAT I CAN T SLEEP 29. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number) STRONGLY DISAGREE NEITHER AGREE AGREE STRONGLY DISAGREE NOR DISAGREE AGREE 30. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem. (circle number) DASH DISABILITY/SYMPTOM SCORE = [(sum of n responses) - 1] x 25, where n is equal to the number of completed responses. n A DASH score may not be calculated if there are greater than 3 missing items.
7 DISABILITIES OF THE ARM, SHOULDER AND HAND WORK MODULE (OPTIONAL) 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 circle the number that best describes your physical ability in the past week. Did you have any difficulty: 1. using your usual technique for your work? 2. doing your usual work because of arm, shoulder or hand pain? 3. doing your work as well as you would like? 4. spending your usual amount of time doing your work? SPORTS/PERFORMING ARTS MODULE (OPTIONAL) 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), please 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 circle the number that best describes your physical ability in the past week. Did you have any difficulty: 1. using your usual technique for playing your instrument or sport? 2. playing your musical instrument or sport because of arm, shoulder or hand pain? 3. playing your musical instrument or sport as well as you would like? 4. spending your usual amount of time practising or playing your instrument or sport? SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by 4 (number of items); subtract 1; multiply by 25. An optional module score may not be calculated if there are any missing items. INSTITUTE FOR WORK & HEALTH ALL RIGHTS RESERVED.
8 THE QuickDASH OUTCOME MEASURE 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 circling the appropriate number. 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 the 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.
9 QuickDASH Please rate your ability to do the following activities in the last week by circling the number below the appropriate response. 1. Open a tight or new jar. 2. Do heavy household chores (e.g., wash walls, floors). 3. Carry a shopping bag or briefcase. 4. Wash your back. 5. Use a knife to cut food. 6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.). NOT AT ALL SLIGHTLY MODERATELY QUITE A BIT EXTREMELY 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? NOT LIMITED SLIGHTLY MODERATELY VERY AT ALL LIMITED LIMITED LIMITED 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? Please rate the severity of the following symptoms in the last week. (circle number) NONE MILD MODERATE SEVERE EXTREME 9. Arm, shoulder or hand pain. 10. Tingling (pins and needles) in your arm, shoulder or hand. SO MUCH DIFFICULTY THAT I CAN T SLEEP 11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number) QuickDASH DISABILITY/SYMPTOM SCORE = of completed responses. ( ) (sum of n responses) - 1 x 25, where n is equal to the number n A QuickDASH score may not be calculated if there is greater than 1 missing item.
10 QuickDASH WORK MODULE (OPTIONAL) 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 circle the number that best describes your physical ability in the past week. Did you have any difficulty: 1. using your usual technique for your work? 2. doing your usual work because of arm, shoulder or hand pain? 3. doing your work as well as you would like? 4. spending your usual amount of time doing your work? SPORTS/PERFORMING ARTS MODULE (OPTIONAL) 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), please answer with respect to that activity which is most important to you. Pleaseindicatethesportorinstrumentwhichismostimportanttoyou : _ I do not play a sport or an instrument. (You may skip this section.) Please circle the number that best describes your physical ability in the past week. Did you have any difficulty: 1. using your usual technique for playing your instrument or sport? 2. playing your musical instrument or sport because of arm, shoulder or hand pain? 3. playing your musical instrument or sport as well as you would like? 4. spending your usual amount of time practising or playing your instrument or sport? SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by 4 (number of items); subtract 1; multiply by 25. An optional module score may not be calculated if there are any missing items. INSTITUTE FOR WORK & HEALTH ALL RIGHTS RESERVED
INSURANCE INFORMATION FOR MOTOR VEHICLE ACCIDENT CLAIMS. Date of Accident- YYYY-MM-DD - - Your name -
INSURANCE INFORMATION FOR MOTOR VEHICLE ACCIDENT CLAIMS Date of Accident- YYYY-MM-DD - - Your name - Name of car insurance company- Branch Location- Name of insurance adjuster- Telephone - Fax- - Name
ACTIVITY LEFT ARM RIGHT ARM
SHOULDER ASSESSMENT FORM AMERICAN SHOULDER AND ELBOW SURGEONS Side: R L Device: RSP TSA Hemi DOS: Side: R L Device: RSP TSA Hemi DOS: Circle the number in the box that indicates your ability to do the
my personal joint profile Your own personal profile of how rheumatoid arthritis is affecting your joints.
my personal joint profile Your own personal profile of how rheumatoid arthritis is affecting your joints. What you and your rheumatologist can learn from your joint profile. It seems like a simple question:
LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B
1 Patient Name In order to properly assess your condition, we must understand how much your BACK/LEG (SCIATIC) PAIN has affected your ability to manage everyday activities. For each item below, please
Cardiff and Vale Spinal Unit Mr M J H McCarthy FRCS
Cardiff and Vale Spinal Unit Mr M J H McCarthy FRCS NECK / ARM PAIN QUESTIONNAIRE Affix Patient Label This document contains a series of standard assessments that are very useful in helping us assess your
Upper Arm. Shoulder Blades R L B R L B WHICH SIDE IS MORE PAINFUL? (CERVICAL PAIN SIDE) RIGHT LEFT EQUAL NOT APPLICABLE (N/A) CERVICAL.
1 NECK PAIN Patient Name In order to properly assess your condition, we must understand how much your NECK/ARM problems has affected your ability to manage everyday activities. For each item below, please
65-69y 70-75 y 76-100y MEN 144.3 ± 58.6 102.4 ± 53.7 101.8 ±45.7 WOMEN 112.7 ± 64.2 89.1 ± 55.5 62.3 ±50.7
1 Physical Activity Scale for the Elderly (PASE) The PASE is an instrument that measures the level of physical activity for individuals aged 65 and older. The PASE is comprised of self-reported occupational,
Cervical Spine. New Patient Form
Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right
Aberdeen Low Back Pain Scale. Overview:
Aberdeen Low Back Pain Scale Overview: Ruta et al all used a questionnaire to measure outcome in patients with low back pain. This can be used for initial evaluation of the patient and to monitor the effectiveness
CRITÉRIOS DE AVALIAÇÃO DE QUALIDADE DE VIDA
CRITÉRIOS DE AVALIAÇÃO DE QUALIDADE DE VIDA S1 SF36 General Health Survey Patient Name Patient ID Study Name Study Number Date / / Side Right Left Filled in by: Operating Dr. Other MD Research Assistant
Questions Concerning Activities of Daily Living (ADL)
Questions Concerning Activities of Daily Living (ADL) Please fill out this form carefully and mark only one box for each question. 1. How well can you perform personal self care activities including washing,
Medical Massage Client Intake Form Medical Massage Client Intake Form
Medical Massage Client Intake Form Medical Massage Client Intake Form Client Name: Date: Please note: The more information you are able to provide, the better equipped our therapists will be to help you.
Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36)
Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36) bout: The SF-36 is an indicator overall health status. Items: 10 Reliability: Most se studies that examined reliability SF_36 have
Stroke Impact Scale VERSION 3.0
Stroke Impact Scale VERSION 3.0 The purpose of this questionnaire is to evaluate how stroke has impacted your health and life. We want to know from YOUR POINT OF VIEW how stroke has affected you. We will
Auto Accident Description
Automotive Accident Form Billing Information Patient name: Date of injury: Time of injury: AM PM City and street where accident occurred: What is the estimated damage to your vehicle? $ Do you have automobile
Quality of Life. Questionnaire 3. 4 weeks after randomisation. Graag in laten vullen door geincludeerde patiënt METEX studie
Patient registration label Quality of Life Questionnaire 3 4 weeks after randomisation Graag in laten vullen door geincludeerde patiënt Patient Identification Number Datum van invullen 1 SF-36 HEALTH SURVEY
Dear Patient, Sincerely, Your Spine Team. Alan Dacre, M.D. Jennifer Kuhr PA-C Michael Guiles PA-C
Dear Patient, Adult Reconstruction Hip & Knee Dean C. Sukin, MD John R. Wilson, MD Foot & Ankle Michael R. Yorgason, MD General Orthopedics John R. Dorr, MD Hand & Upper Extremity Ralph M. Costanzo, MD
Patients Signature Date. Guardian or Spouse s Signature who authorize care. Phone#: Relationship Phone#:
Hands On Chiropractic I understand and agree that health and insurance policies are an arrangement between an insurance carrier and my self. Furthermore, I understand Hands On Chiropractic will prepare
Understanding your Peripherally Inserted Central Catheter (PICC) Patient Information
Understanding your Peripherally Inserted Central Catheter (PICC) Patient Information The Purpose of this Information Sheet This information sheet has been written by patients, members of the public and
Accident Claim Number - You Have Been Laid, Now What?
Personal Injury Information First Name: / / Address: City/Town: Last Name: Phone: State: Zip Code: Your Auto Ins. Co Phone: Address: Accident Claim #: Agent s Name: Driver/Other Vehicle: Ins. Co: Policy
SAMPLE QUESTIONNAIRE
Stanford Patient Education Research Center Stanford University School of Medicine SAMPLE QUESTIONNAIRE CHRONIC DISEASE August 2007 You may use all or parts of the questionnaire at no charge without permission
Chest (medicine ball)
Kneel to Pushup Kneel to Pushup Start Position: Your body will be in an upright position sitting on your knees. Hold medicine ball at chest level. Keeping your torso erect fall forward and chest press
BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )
PATIENT INFORMATION SOCIAL SECURITY # MARRIED SINGLE WIDOW DIVORCED NAME Last First MI HOME ADDRESS BILLING ADDRESS ACCT# DRIVER S LICENSE# BIRTHDATE - - AGE SEX CITY STATE ZIP CITY STATE ZIP PHONE HOME(
Insurance Information
Patient File#: AUTO ACCIDENT HISTORY WELCOME: The doctor and staff welcome you and want you to provide you with the best possible care. We will conduct a thorough history and physical examination to decide
Multiplying Integers. Lesson Plan
Lesson Plan Video: 12 minutes Lesson: 38 minutes Pre-viewing :00 Warm up: Write 5 + 5 + 5 + 5 = on the board. Ask students for the answer. Then write 5 x 4 = on the board. Ask the students for the answer.
Axillary Lymph Node Dissection: Instructions/Exercises
Axillary Lymph Node Dissection: Instructions/Exercises The following activities have been approved by your physician to help you increase the motion and strength of your shoulder and improve your posture
STRAIN INJURIES. Summary of the law on
Summary of the law on STRAIN INJURIES Workers who suffer from pain and stiffness in any of their upper limbs because of something they do at work may be suffering from strain injury categorised as a work
Cast removal what to expect #3 Patient Information Leaflet
Cast removal what to expect #3 Patient Information Leaflet SM466 Now your cast is off, self help is the key! Follow the advice given to you by your doctor and the staff in the clinic. Your skin will be
Patient Basic Information
Patient Basic Information Personal Information: Last Name: First Name: Mid. Init.: Address: City, State, Zip: Home Phone: Work Phone: Social Security No.: Date of Birth: Date of Injury/Onset: Dominant
Going home after an AV Fistula or AV Graft
Going home after an AV Fistula or AV Graft TGH Information for patients and families During your hospital stay, your surgeon created an: AV Fistula AV Graft Read this booklet to learn: how to care for
Matthew D. Kaplan, LLC. Personal Injury Client Interview Form
Matthew D. Kaplan, LLC PLEASE TAKE YOUR TIME IN COMPLETING THIS QUESTIONNAIRE. IT IS VERY IMPORTANT TO YOUR CASE THAT THIS INFORMATION IS AS THOROUGH AND ACCURATE AS POSSIBLE. Personal Injury Client Interview
ST-GEORGE RESPIRATORY QUESTIONNAIRE (SGRQ)
Pre-rehabilitation evaluation (visit 1) Post-rehabilitation evaluation < 1 month (visit 2) Post-rehabilitation evaluation : 1 yr (visit 3) 2 yrs (visit 4) 3 yrs (visit 5) Date yyyy-mmm-dd Time at the beginning
The RAND 36-Item Health Survey
The RAND 36-Item Health Survey Introduction The RAND 36-Item Health Survey (Version 1.0) laps eight concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations
St. George s Respiratory Questionnaire PART 1
ST. GEORGE S RESPIRATORY QUESTIONNAIRE ORIGINAL ENGLISH VERSION ST. GEORGE S RESPIRATORY QUESTIONNAIRE (SGRQ) This questionnaire is designed to help us learn much more about how your breathing is troubling
Oxford University Hospitals. NHS Trust. Hand & Plastics Physiotherapy Department Flexor Tendon Repair. Information for patients
Oxford University Hospitals NHS Trust Hand & Plastics Physiotherapy Department Flexor Tendon Repair Information for patients Introduction You have had surgery to repair one or more of the tendons in your
A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course
2014 Annual Breast Cancer Rehabilitation Healthcare Provider Event A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course November 7 th and 8 th, 2014 Mercer University, Atlanta,
Auto Accident Questionnaire
Auto Accident Questionnaire Patient s Name: Date Of Accident: Date: Social History: (please complete the following, check all boxes that apply) Are you: Married Single Divorced Widowed # of Children: #
PATIENT REGISTRATION Chitranjan Ranawat Amar Ranawat Anil Ranawat
PATIENT REGISTRATION Chitranjan Ranawat Amar Ranawat Anil Ranawat Last Name First Name Address City State Zip Sex M F Date of Birth SS # - - Home Phone Work Cell Occupation presently working Yes NO Email
Wrist Fractures Looking for more health information?
2011 Wrist Fractures Notes Wrist Fractures After your cast is taken off you will likely feel some joint and soft tissue tightness of the injured forearm. You may have one or more of the these wrist and
Foot and Ankle Outcomes Questionnaire
Foot and Ankle Outcomes Questionnaire Developed by: American Academy of Orthopaedic Surgeons American Association of Hip and Knee Surgeons American Orthopaedic Society for Sports Medicine Hip Society Knee
WHODAS 2.0 World Health Organization Disability Assessment Schedule 2.0 36-item version, self-administered
The APA is offering a number of emerging measures for further research and clinical evaluation. These patient assessment measures were developed to be administered at the initial patient interview and
Account Payment Details
date / / title Mrs Miss Ms Mr Mast Dr family name given name address date of birth email phone h w m medicare number exp Medicare Reference Number (Small Number in front of your name) SMS message reminder:
Shoulder Tendonitis. Brett Sanders, MD Center For Sports Medicine and Orthopaedic 2415 McCallie Ave. Chattanooga, TN (423) 624-2696
Shoulder Tendonitis Brett Sanders, MD Center For Sports Medicine and Orthopaedic 2415 McCallie Ave. Chattanooga, TN (423) 624-2696 Shoulder tendinitis is a common overuse injury in sports (such as swimming,
Primary Intra-school/Level 1 Resource - Challenge Card
Primary Intra-school/Level 1 Resource - Challenge Card handball - wall ball Quick introduction Wall ball is a team game played by throwing a ball against a wall. The aim of the game is for the next player
(3) Doing work around the house, such as cleaning, light yard work or home maintenance?
Functional Status Questionnaire Overview: The Functional Status Questionnaire can be used as a self-administered functional assessment for a patient seen in primary care. It provides information on the
Employment & Support Allowance. Physical Health Grounds
Employment & Support Allowance claims on Physical Health Grounds A guide to the Work Capability Assessment (Full January 2013 Changes) May 2013 Authors: Steve Donnison & Holiday Whitehead (Barrister) INDEX
UPPER QUADRANT PAC. Do only those exercises that I have checked off for you to do independently. THINGS TO AVOID
UPPER QUADRANT PAC Most common pain / disfunction syndromes occur as a result of a combination of poor posture habit and imbalanced muscle groups. The following exercise protocols will address the most
S.CP.A.1: Venn Diagrams
Regents Exam Questions www.jmap.org Name: 1 Monique has three sons who play football, two sons who play baseball, and one son who plays both sports. If all of her sons play baseball or football, how many
Exercise and advice after breast cancer surgery
Exercise and advice after breast cancer surgery Irving Building Physiotherapy All Rights Reserved 2015. Document for issue as handout. Role of the physiotherapist Exercises for the first week following
Indian Trail Chiropractic & Rehab., P.A.
100 Park Road East. Indian Trail, NC 28079 704-821-3222 Patient Information Name; First: Middle: Last: Address: Today's Date: Patient Number: City: State: Zip: Phone; (H): (W): (Cell): Email Preferred
Chemotherapy Side Effects Worksheet
Page 1 of 6 Chemotherapy Side Effects Worksheet Medicines or drugs that destroy cancer cells are called cancer chemotherapy. It is sometimes the first choice for treating many cancers. Chemotherapy differs
Partnerships Implementing Engineering Education Worcester Polytechnic Institute Worcester Public Schools
Partnerships Implementing Engineering Education Worcester Polytechnic Institute Worcester Public Schools Supported by: National Science Foundation Simple Machines: 4.G.1 Introduction to Simple Machines
Auto Accident/Personal Injury Information
Auto Accident/Personal Injury Information Patient s Name: Today s Date: Personal Injury Information Date of Accident: Time of Accident: am/pm Did police arrive on scene? [ ] Yes [ ] No Is there a report?
McGILL QUALITY OF LIFE QUESTIONNAIRE
McGILL QUALITY OF LIFE QUESTIONNAIRE STUDY IDENTIFICATION #: DATE: Instructions The questions in this questionnaire begin with a statement followed by two opposite answers. Numbers extend from one extreme
2. Timeliness: If you are more than 15 minutes late, we may ask you to reschedule your appointment.
Welcome to our clinic! Our goal at University of Wisconsin Hospital & Clinics is to offer the best possible care to our patients. We want to work with you to make that happen. To best work as a health
Oswestry Low Back Pain Disability Questionnaire Oswestry Disability Index
Appendix D Oswestry Low Back Pain Disability Questionnaire Please complete this questionnaire. It is designed to tell us how your back pain affects your ability to function in every day life. I have Chronic
REVISED E-Health Patient Screening Survey
REVISED E-Health Patient Screening Survey The Patient screening survey will be administered online after the patient has electronically signed the patient consent form. 1 E-Health Patient Screening Survey
PI MEDPAY FORM. [J Do I have Medpay? [] How much Medpay do I have? [ ] Do I have primary or excess Medpay? [ ] Adjuster name and phone number
![PI MEDPAY FORM. [J Do I have Medpay? [] How much Medpay do I have? [ ] Do I have primary or excess Medpay? [ ] Adjuster name and phone number](/thumbs/24/3718419.jpg "PI MEDPAY FORM. [J Do I have Medpay? [] How much Medpay do I have? [ ] Do I have primary or excess Medpay? [ ] Adjuster name and phone number")
PI MEDPAY FORM [J Do I have Medpay? [] How much Medpay do I have? [ ] Do I have primary or excess Medpay? [ ] Adjuster name and phone number [] Claim # PERSONAL INJURY QUES1"IONNAIRE Name: ----------------
QWALL 4 ACRYLIC SHOWER WALL INSTALLATION INSTRUCTIONS
QWALL 4 ACRYLIC SHOWER WALL INSTALLATION INSTRUCTIONS IMPORTANT DreamLine TM reserves the right to alter, modify or redesign products at any time without prior notice. For the latest up-to-date technical
Time management, study plans, and exams
Time management, study plans, and exams The best strategy for avoiding stress and anxiety about homework, assignments and exams is an effective and consistent study plan teamed with good time management.
Information for patients Exercise and advice after breast cancer surgery
Information for patients Exercise and advice after breast cancer surgery Physiotherapy Salford Royal NHS Foundation Trust Stott Lane, Salford, M6 8HD Telephone: 0161 206 5328 Page 1 of 5 Role of the physiotherapist
How To Be Active
Be Active Your Way A Guide for Adults Based on the 2008 Physical Activity Guidelines for Americans Be Active, Healthy, and Happy! Be Active Your Way A Guide for Adults Wondering about how much activity
WORKER S COMPENSATION HISTORY FORM NAME (Last, First, Middle Initial) Height Weight
341 Magnolia Avenue, Suite 101 28078 Baxter Road, Suite 330 Corona, CA 92879 Murrieta, CA 92563 (951) 735-6060 (951) 735-4510 Fax (951) 677-2157 www.ctoamg.com WORKER S COMPENSATION HISTORY FORM NAME (Last,
Hand Injuries and Disorders
Hand Injuries and Disorders Introduction Each of your hands has 27 bones, 15 joints and approximately 20 muscles. There are many common problems that can affect your hands. Hand problems can be caused
Treatment Options for Rotator Cuff Tears A Guide for Adults
Treatment Options for Rotator Cuff Tears A Guide for Adults Is This Guide for Me? YES, if your doctor has told you that you have a rotator cuff tear, which is an injury to one or more of the muscles and
Exercise therapy in the management of upper limb dysfunction in people with Rheumatoid Arthritis. Speaker declaration: no conflicts of interest
Exercise therapy in the management of upper limb dysfunction in people with Rheumatoid Arthritis Speaker declaration: no conflicts of interest Exercise a planned, structured and repetitive bodily movement
WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
Physical Capability Strength Test: One Component of the Selection Process
Physical Capability Strength Test: One Component of the Selection Process One aspect of the Power Systems Institute selection process is to successfully complete and achieve a passing score on a physical
SHOULDER REHABILITATION EXERCISE PROGRAM. Phase I
Franklin Orthopedics 7400 W Rawson Ave, Suite 225 Franklin, WI 53132 414-425-8232 SHOULDER REHABILITATION EXERCISE PROGRAM Phase I PENDULUM EXERCISES: Bending over at the waist and balancing with the good
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
150640_Brochure_B 4/12/07 2:58 PM Page 2. Patient Information. Freedom From an Enlarged Prostate
150640_Brochure_B 4/12/07 2:58 PM Page 2 Patient Information Freedom From an Enlarged Prostate 150640_Brochure_B 4/12/07 2:58 PM Page 3 GreenLight Laser Therapy 1 150640_Brochure_B 4/12/07 2:58 PM Page
City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:
Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work
Hip and Knee Outcomes Questionnaire
Hip and Knee Outcomes Questionnaire Developed by: American Academy of Orthopaedic Surgeons American Association of Hip and Knee Surgeons American Orthopaedic Society for Sports Medicine Hip Society Knee
AwanaGames Circle. Official. Diagram 1. Key to diagram: Pin & Striped Bean Bag C Diagonal or Starting Line. B Scoring Pins, or Center.
Official AwanaGames Circle Diagram 1 The AwanaGames Circle is 30 feet in diameter surrounded by a 37-40 foot square. Each team is designated by a color and occupies a quarter-circle or one side of that
ERGONOMICS IN CONSTRUCTION
1.0 1.0 Facilitator / Leader Tasks Before the Tool Box Talk (TBT): 1. Read through this TBT guide. 2. Walk the job site to find ergonomics examples based on the TBT. If possible, take photos of safe and
Rotator Cuff Surgery: Post-Operative Protocol for Mini-Open or Arthroscopic Rotator Cuff Repair
Rotator Cuff Surgery: Post-Operative Protocol for Mini-Open or Arthroscopic Rotator Cuff Repair Considerations: 1. Mini-Open - shoulder usually assessed arthroscopically and acromioplasty is usually performed.
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with
Premier Healthcare of Placerville
Premier Healthcare of Placerville 1980 Broadway, Placerville, CA 95667 (530) 622-3536 Fax (530) 622-3538 WORKERS COMPENSATION INJURY QUESTIONNAIRE Name: Social Security#: of Birth: Today s : To insure
Journal. A workbook designed to organize and survey your incident & injury throughout the road to recovery. tywilsonlaw.
YOUR INJURY Journal A workbook designed to organize and survey your incident & injury throughout the road to recovery SLIP/FALL CAR ACCIDENT WORKERS COMP TY WILSON LAW tywilsonlaw.com 866-937-5454 YOUR
Frozen shoulder (adhesive capsulitis)
Patient information Frozen shoulder (adhesive capsulitis) This information has been produced to help you gain the maximum benefit and understanding of your operation. It includes the following information:
I am seeking help for: Which is limiting me from: When and how did this issue begin? What makes it worse? What makes it better?
Shine Integrative Physical Therapy Intake Form First name Middle Last Birthdate / / How did you hear about us? Address City State Zip Home phone Cell phone Email address Occupation Emergency contact Phone
ARTHROSCOPIC ROTATOR CUFF REPAIR PROTOCOL (DR. ROLF)
ARTHROSCOPIC ROTATOR CUFF REPAIR PROTOCOL (DR. ROLF) Phase I Immediate Post Surgical Phase (Weeks 1-4): Maintain integrity of repair Diminish pain and inflammation Prevent muscular inhibition Independent
COMPREHENSIVE HIGH SCHOOL TRANSITION SURVEY TRANSITION ASSESSMENT/INTERESTS, PREFERENCES, STRENGTHS & NEEDS. Full Name: Birthdate: / / Age:
COMPREHENSIVE HIGH SCHOOL TRANSITION SURVEY TRANSITION ASSESSMENT/INTERESTS, PREFERENCES, STRENGTHS & NEEDS Full Name: Birthdate: / / Age: Address: Phone #: Cell #: Disability: Parent/Guardian Name: Work
National Eye Institute Visual Functioning Questionnaire - 25 (VFQ-25) (INTERVIEWER ADMINISTERED FORMAT)
PB/IA National Eye Institute Visual Functioning Questionnaire - 25 (VFQ-25) version 2000 (INTERVIEWER ADMINISTERED FORMAT) January 2000 RAND hereby grants permission to use the "National Eye Institute
Elbow Joint Replacement A guide for patients
Elbow Joint Replacement A guide for patients GATESHEAD UPPER LIMB UNIT Mr Andreas Hinsche Mr John Harrison Mr Jagannath Chakravarthy Page 1 of 7 The elbow joint The elbow consists of three bones; the humerus
Acute Oncology Service Patient Information Leaflet
Spinal cord compression Acute Oncology Service Patient Information Leaflet Introduction If you have been diagnosed with cancer, you need to know about spinal cord compression and the warning signs. What
.org. Rotator Cuff Tears. Anatomy. Description
Rotator Cuff Tears Page ( 1 ) A rotator cuff tear is a common cause of pain and disability among adults. In 2008, close to 2 million people in the United States went to their doctors because of a rotator
Sue Schuerman, PT, GCS, PhD UNLVPT
Sue Schuerman, PT, GCS, PhD UNLVPT Exercise & Physical Activity (Your Everyday Guide from the National Institute on Aging) Go4Life Retain our physical and mental health Continue to do the things we enjoy
Target Heart Rate and Estimated Maximum Heart Rate
Target Heart Rate and Estimated Maximum Heart Rate One way of monitoring physical activity intensity is to determine whether a person's pulse or heart rate is within the target zone during physical activity.
Auto Accident Questionnaire. Auto Insurance Information (please present a copy of your auto insurance card)
Auto Accident Questionnaire name today s date date of accident date of birth age gender marital status # of children address street city state zip home phone cell phone email occupation company name city
Getting over back pain. A practical guide to dealing with back pain and getting on with your life
Getting over back pain A practical guide to dealing with back pain and getting on with your life Short-term back pain is very common eight out of 10 New Zealanders have to deal with back pain at some stage
*Date of injury/auto Accident/Slip and fall: / / Time: : AM PM
Oasis Chiropractic Injury/ Auto Accident/ Slip & Fall Form First Name: Last Name: Title: (check one) Mr. Mrs. Ms. Miss Dr. Other Patient ID#: Single Married Widowed Under 18 (Minor) Separated Divorced
ROTATOR CUFF HOME EXERCISE PROGRAM
ROTATOR CUFF HOME EXERCISE PROGRAM Contact us! Vanderbilt Sports Medicine Medical Center East, South Tower, Suite 3200 1215 21st Avenue South Nashville, TN 37232-8828 For more information on this and other
Living a Full Life with Fibro 60 Day Action Plan
Living a Full Life with Fibro 0 Action Plan In preparation for a visit to your physician, take the time to complete the 0 Action Plan for fibromyalgia, which can provide you and your physician with a better
Returning to fitness after heart surgery
Returning to fitness after heart surgery A patient s guide 1 Increasing activity After your operation, your heart function should be improved and so your ability to exercise will also be improved. However,
Medicare Health Outcomes Survey Modified (HOS-M) Questionnaire (English) Insert HOS-M Cover Art (English)
Medicare Health Outcomes Survey Modified (HOS-M) Questionnaire (English) 06 Insert HOS-M Cover Art (English) Medicare Health Outcomes Survey Modified Instructions This survey asks about your health, feelings,
NIOSH has developed an observational assessment tool for dampness and mold in buildings.
NIOSH has developed an observational assessment tool for dampness and mold in buildings. GOAL: To provide valuable information for motivating remediation, prioritizing intervention, and evaluating remediation
Function First Physical Therapy, P.C. Patient Intake Form
Patient Intake Form Patient Information: Last Name: First Name: Sex: Date of Birth: SS#: - - Address: City: State: Zip Code: Work#: ( ) - Home#: ( ) - Email: Mobile#: ( ) - Marital Status: Single Married
PERSONAL INFORMATION
Date: Bruns Chiropractic Clinic EXISTING PATIENT INTAKE FORM (For patients treated within the past 3 years) PERSONAL INFORMATION Name: First MI Last Preferred Name: Gender: M F DOB: / / Age Social Security
HALO ORTHOSIS. 1. The ring and pins. 2. The vest. 3. The superstructure (uprights that connect the ring to the vest)
UM Orthotics & Prosthetics Center UM Orthopaedics UM Neurosurgery HALO ORTHOSIS HALO Front View HALO Back View You have been placed in a halo vest. This orthosis (brace) is used to immobilize a neck fracture