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Elbow Function Assessment
elbowadmin
2022-11-02T13:00:52+00:00
Elbow Function Assessment
"
*
" indicates required fields
Step
1
of
6
16%
Name
*
Date of Birth
*
DD slash MM slash YYYY
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
*
DD slash MM slash YYYY
Time Post-op
*
3 weeks
6 weeks
4 months
6 months
1 year
2 years
Other
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?
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