Name

Email Address

Open a tight or new jar Open a tight or new jar 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Write Write 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Turn a key Turn a key 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Prepare a meal Prepare a meal 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Push open a heavy door Push open a heavy door 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Place an object above your head Place an object above your head 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Do heavy household chores (e.g wash wall, wash floors, wash floors) Do heavy household chores (e.g wash wall, wash floors, wash floors) 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Garden or yard work Garden or yard work 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Make a bed Make a bed 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Carry a shopping bag or briefcase Carry a shopping bag or briefcase 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Wash or blow dry your hair Wash or blow dry your hair 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Wash your back Wash your back 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Put a pullover sweater Put a pullover sweater 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Use a knife to cut food Use a knife to cut food 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Recreational activities which require little effort (e.g card playing, knitting, etc.) Recreational activities which require little effort (e.g card playing, knitting, etc.) 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

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 take some force or impact through your arm, shoulder, or hand (e.g golf, hammering, tennis, etc.) 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Recreational activities in which you move your arm freely (e.g playing frisbee, badminton, etc.) Recreational activities in which you move your arm freely (e.g playing frisbee, badminton, etc.) 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Manage transportation needs (getting from one place to another) Manage transportation needs (getting from one place to another) 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

Sexual activities Sexual activities 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (UNABLE)

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? 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? 1 (NOT LIMITED AT ALL) 2 (SLIGHTLY LIMITED) 3 (MODERATELY LIMITED) 4 (VERY LIMITED) 5 (UNABLE)

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, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem? 1 (NOT LIMITED AT ALL) 2 (SLIGHTLY LIMITED) 3 (MODERATELY LIMITED) 4 (VERY LIMITED) 5 (UNABLE)

Arm, shoulder or hand pain level Arm, shoulder or hand pain level 1 (None) 2 (Mild) 3 (Moderate) 4 (Severe) 5 (Extreme)

Arm, shoulder or hand pain when you performed any specific activity Arm, shoulder or hand pain when you performed any specific activity 1 (None) 2 (Mild) 3 (Moderate) 4 (Severe) 5 (Extreme)

Tingling (pins & needles) in your arm, shoulder, or hand Tingling (pins & needles) in your arm, shoulder, or hand 1 (None) 2 (Mild) 3 (Moderate) 4 (Severe) 5 (Extreme)

Weakness in your arm, shoulder, or hand Weakness in your arm, shoulder, or hand 1 (None) 2 (Mild) 3 (Moderate) 4 (Severe) 5 (Extreme)

Stiffness in your arm, shoulder, or hand Stiffness in your arm, shoulder, or hand 1 (None) 2 (Mild) 3 (Moderate) 4 (Severe) 5 (Extreme)

During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? 1 (NO DIFFICULTY) 2 (MILD DIFFICULTY) 3 (MODERATE DIFFICULTY) 4 (SEVERE DIFFICULTY) 5 (SO MUCH DIFFICULTY THAT I CAN'T SLEEP)

I feel less capable, less confident or less useful because of my arm. shoulder or hand problem. I feel less capable, less confident or less useful because of my arm. shoulder or hand problem. 1 (STRONLY DISAGREE) 2 (DISAGREE) 3 (NEITHER AFREE NOR DISAGREE) 4 (AGREE) 5 (STRONGLY AGREE)