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Elbow Function Assessmentelbowadmin2016-08-05T09:53:31+00:00

Elbow Function Assessment

Step 1 of 6

16%

Name*
Date of Birth*
Hospital Number*
Affected Side*
- Right
- Left
Dominant Arm*
- Right
- Left

Pain
Level of Pain at Rest*
If 0 means no pain and 10 means the worst pain you can have, please click the number which describes your elbow pain when you are not doing any activities.
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Level of Pain on Motion*
If 0 means no pain and 10 means the worst pain you can have, please click the number which describes your elbow pain when you are moving your elbow.
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10

Function
Have you had any trouble raising a cup to your mouth?*
- Impossible to do
- With aid
- With much difficulty
- With little difficulty
- Without difficulty
Have you had any trouble eating with a spoon?*
- Impossible to do
- With aid
- With much difficulty
- With little difficulty
- Without difficulty
Have you had any trouble lifting a kettle with one litre of water?*
- Impossible to do
- With aid
- With much difficulty
- With little difficulty
- Without difficulty
Have you had any trouble pouring water from a kettle into a glass?*
- Impossible to do
- With aid
- With much difficulty
- With little difficulty
- Without difficulty
Have you had any trouble cutting with a knife?*
- Impossible to do
- With aid
- With much difficulty
- With little difficulty
- Without difficulty
Have you had any trouble cutting with a knife?*
- Impossible to do
- With aid
- With much difficulty
- With little difficulty
- Without difficulty
Have you had any trouble pulling an object across a table?*
- Impossible to do
- With aid
- With much difficulty
- With little difficulty
- Without difficulty

Quick Dash Form

Please rate your ability to do the following activites in the last week by circling the number below the appropriate response.
Open a tight or new jar*
- No difficulty
- Mild difficulty
- Moderate difficulty
- Severe difficulty
- Unable
Do heavy household chores (e.g. wash walls, floors)*
- No difficulty
- Mild difficulty
- Moderate difficulty
- Severe difficulty
- Unable
Carry a shopping bag or briefcase*
- No difficulty
- Mild difficulty
- Moderate difficulty
- Severe difficulty
- Unable
Wash your back*
- No difficulty
- Mild difficulty
- Moderate difficulty
- Severe difficulty
- Unable
Use a knife to cut food*
- No difficulty
- Mild difficulty
- Moderate difficulty
- Severe difficulty
- Unable
Recreational activities in which you take some force or impact through your elbow (e.g. golf, hammering, tennis, etc.)*
- No difficulty
- Mild difficulty
- Moderate difficulty
- Severe difficulty
- Unable
Were you limited in your work or other regular daily activities as a result of your elbow or hand problem?*
- Not limited at all
- Slightly limited
- Moderately limited
- Very limited
- Unable
Shoulder or arm pain*
- None
- Mild
- Moderate
- Severe
- Extreme
Tingling (pins & needles) in your arm or hand*
- None
- Mild
- Moderate
- Severe
- Extreme
During the past week, how much difficulty have you had sleeping because of pain in your elbow or hand?*
- No difficulty
- Mild difficulty
- Moderate difficulty
- Severe difficulty
- Unable

Have you had an operation?*
- Yes
- No
Post-op Questions

Only complete this section if you have had an operation.
Operation*
Date of Operation*
Time Post-op*
- 3 weeks
- 6 weeks
- 4 months
- 6 months
- 1 year
- 2 years
How do you feel now, following your operation?*
- Much better
- Better
- Same
- Worse
- Much worse
What percentage improvement have you had since the operation?*
- 0%
- 10%
- 20%
- 30%
- 40%
- 50%
- 60%
- 70%
- 80%
- 90%
- 100%
Have you now:*
- Returned to the same occupation
- Returned to the same occupation but with decreased level of activity (due to the elbow)
- Changed occupation due to the elbow
- Stopped working all together because of your elbow
If you have changed occupation, what job do you do now?
Have you now:*
- Returned to the same level of activity in the same sport
- Returned to a decreased level of activity in the same sport because of the elbow
- Changed sports because of the elbow
- Stopped playing sports altogether because of the elbow
If you have changed sports, what have you changed to?

Comments

Mr A Watts Ltd.
Registered office: c/o Sandison
Easson & Co, Rex Buldings,
Alderley Road, Wilmslow, SK9 1HY

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