*

First Name

Last Name

How satisfied are you with the level of care and service provided? *

Very Satisfied

Satisfied

Unsatisfied

Very unsatisfied

Please rate your progress with functional activities from start of therapy to present: *

Excellent

Good

Fair

Poor

At this point in your treatment, have your therapy goals been met? *

Completely met

Mostly met

Partially met

Not met

Please rate your ability to open a tight or new jar *

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

5 Unable

Please rate your ability to do heavy household chores (e.g., wash walls, floors) *

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

5 Unable

Please rate your ability to carry a shopping bag or briefcase *

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

5 Unable

Please rate your ability to wash your back *

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

5 Unable

Please rate your ability to use a knife to cut food *

1 No difficulty

2 Mild difficulty

3 Moderate difficulty

4 Severe difficulty

5 Unable

Please rate your ability to do recreational activities in which you take some impact through your arm or shoulder (e.g., golf, hammering, tennis, etc.) *

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 issue interfered with your normal social activites? *

1 Not at all

2 Slightly

3 Moderately

4 Quite a bit

5 Extremely

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

Please rate the severity of arm, shoulder, or hand pain in the past week *

1 None

2 Mild

3 Moderate

4 Severe

5 Extreme

Please rate the severity of tingling (pins and needles) in your arm, shoulder, or hand in the past week *

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? *

1 None

2 Mild

3 Moderate

4 Severe

5 Extreme; can't sleep