Outcome Measure.

Date

- note that the month comes first

YYYY

Name

First Name

Last Name

NUMERICAL PAIN RATING SCALE

Please select your average pain in the last 24 hours on a scale of 0 - 10, where 0 equals no pain and 10 equals the worst imaginable pain.

GLOBAL RATING OF CHANGE

Please select how you would describe yourself now with respect to your injury, compared to immediately after your accident?

QUICKDASH

Please rate your ability to do the following activities in the last week by selecting the number beside the appropriate response. Please answer all questions.

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.)

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

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?

RATE THE SEVERITY OF THE FOLLOWING SYMPTOMS IN THE LAST WEEK

9. Arm, shoulder or hand pain

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

11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?

GOAL SETTING

Please write a functional goal relating to an everyday work, home or sporting activity that you hope to achieve during the course of treatment for your injury.