QuickDASH THE INSTRUCTIONS. This questionnaire asks about your symptoms as well as your ability to perform certain activities.
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1 THE QuickDASH OUTCOME MEASURE INSTRUCTIONS This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer every question, based on your condition in the last week, by circling the appropriate number. If you did not have the opportunity to perform an activity in the past week, please make your best estimate of which response would be the most accurate. It doesn't matter which hand or arm you use to perform the activity; please answer based on your ability regardless of how you perform the task.
2 QuickDASH Please rate your ability to do the following activities in the last week by circling the number below the appropriate response. NO MILD MODERATE SEVERE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY UNABLE. Open a tight or new jar.. 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.). NOT AT ALL SLIGHTLY MODERATELY QUITE ABIT EXTREMELY 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? NOT LIMITED AT ALL SLIGHTLY LIMITED MODERATELY LIMITED VERY LIMITED UNABLE 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? Please rate the severity of the following symptoms in the last week. (circle number) 9. Arm, shoulder or hand pain. 0. Tingling (pins and needles) in your arm, shoulder or hand. NONE MILD MODERATE SEVERE EXTREME SO MUCH NO MILD MODERATE SEVERE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY THATI CAN'T SLEEP. During the past week, how rnueh difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number) 3 4 QuichDASH DISABILITY/SYMPTOM SCORE = (fs'um of n responsei)l- \x 5, where n Is equal to the number of completed responses. \[ n J J A QuichDASH score may nm be calculated if there Is greater than missing item.
3 QuickDASH WORK MODULE (OPTIONAL) The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (Including homemaking if that is your main work role). Please indicate what your job/work is: 0 I do not work. (You may skip this section.) Please circle the number that best describes your physical ability in the past week. Did you have any difficulty: NO MILO MODERATE SEVERE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY UNABLE. using your usual technique for your work?. doing your usual work because of arm, shoulder or hand pain? 3. doing your work as well as you would like? 4. spending your usual amount oftime doing your work? SPORTS/PERFORMING ARTS MODULE (OPTIONAL) The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or both. If you play more than one sport or Instrument (or play both), please answer with respect to that activity which is most Important to you. Please indicate the sport or instrument which is most important to you: Q I do not play a sport or an instrument. (You may skip this section.) Please circle the number that best describes your physical ability in the past week. Did you have any difficulty: NO MILD MODERATE SEVERE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY UNABLE. using your usual technique for playing your instrument or sport?. playing your musical instrument or sport because of arm, shoulder or hand pain? 3. playing your musical Instrument or sport as well as you would like? 4. spending your usual amount of time practising or playing your instrument or sport? SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by N Institute I Research Excellence for Work & Advancing Employee 4 (number of items); subtract ; multiply by 5. Health Health An optional module score may rurt be calculated if there are any missing items. NsmurE FOR won«& HEALTH 006. ALL RIGHTS RESERVED
4 Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) (-) Symptom severity scale ( items) How severe is the hand or wrist pain that you have at night?. How often did hand or wrist pain wake you up during a typical night in the past two weeks? 3. Do you typically have pain in your hand or wrist during the daytime? 4. How often do you have hand or wrist pain during daytime? 5. How long on average does an episode of pain last during the daytime? Normal Slight Medium Severe Very serious Normal Once to 3 times More than 5 4 to 5 times times Nopain Slight Medium Severe Very serious Normal ~ times/ day Morethan5 3-5 times / day Continued times Normal < l0minutes 0~60 Continued >60minutes Continued 6. Do you have numbness (loss of sensation) in your hand? Normal Slight Medium Severe Very serious 7. Do you have weakness in your hand or wrist? Normal Slight Medium Severe Very serious 8. Do you have tingling sensations in your hand? Normal Slight Medium Severe Very serious 9. How severe is numbness (loss of sensation) or tingling at night? Normal Slight Medium Severe Very serious 0. How often did hand numbness or tingling wake you up during a typical night during the past two weeks? Normal Once to 3 times 4 to 5 times Morethan5 times. Do you have difficulty with the grasping and use of small Moderately Without difficulty objects such as keys or pens? Little difficulty difficulty Very difficulty Very difficult
5 (.=..) Functional status scale (8 items) : ~ No difficulty Little difficulty Moderate difficulty Intense difficulty Cannot perform the activity at all due to hands and wrists symptoms Writing Buttoning of clothes Holding a book while reading Gripping of a telephone handle Opening of jars Household chores Carrying of grocery basket Bathing and dressing
6 FLORIDA ORTHOPAEDIC INSTITUTE THOMAS M. DAVISON, M.D. EDDY L. ECHOLS, JR., M.D. TIMOTHY C. EPTING, D.O. KENNETH A. GUSTKE, M.D. ANTHONY F. INF ANTE, D.O. BENJAMIN J. MAXSON, D.O. MICHAEL A. MIRANDA, D.O. JASON NYDICK, D.O. JEFFREY D. STONE, M.D. PATIENT QUESTIONNAIRE INITIAL EVALUATION Date: Patient Name: (Office use only) MR# Family/Primary Doctor: Phone: Family/Primary Doctor's Address: Who referred you to Florida Orthopaedic Institute? (name & address please) INSTRUCTIONS: Please complete the following questionnaire before you see the doctor. Circle the word or phrase that best describes your situation. You may select more than one answer per question. Answer the question in as much detail as possible. Write additional information in the margins. The information you provide will help your doctor to more accurately understand your problem(s) and develop an appropriate plan of treatment for your care. THANK YOU. Age: Sex: Marital Status: Height: Weight: Handed: R/L Occupation: What are you seeing the doctor for? Duration of Symptoms: When did the problem first start or when did the injury occur? Is this injury work related? Yes/No Have you seen a doctor in the past for this problem or injury? Yes/ No If yes, who and when? Explain in your own words how this injury occurred: What treatment have you had? Would you be interested in taking part in a research study? Yes / No
7 TELL US ABOUT YOURSELF AND YOUR PAST MEDICAL HISTORY: Circle anything listed below to which you are allergic: No known allergies Penicillin Tetracycline Sulfa Morphine Erythromycin (I) (J) (K) Codeine lodine/betadine Radiographic Dyes Adhesive Tape Circle any of the medical problems listed below that you have now: (I) (J) (K) (L) I have no known medical problems. Hypertension Coronary artery disease Peripheral vascular disease Adult onset diabetes Childhood onset diabetes Past heart attack Asthma Ulcers Hepatitis A / B / C Cancer Tuberculosis (M) (N) (0) (P) (Q) (R) (S) (T) (U) (V) (W) Liver disease Seizure disorder Thyroid disease Emphysema COPD/Lung problem Immune disorder Overweight Osteomyelitis Blood Clot (DVT) Osteoporosis How much alcohol do you consume? I'm a non-drinker I'm a recovering alcoholic I drink only occasionally I drink weekends only An average of - drinks per day An average of-3 drinks per day An average of 3-4 drinks per day More than 6 drinks a day Do you now, or have you ever smoked cigarettes? Yes, I am currently a smoker I smoke ( circle one) 3 packs/day I have smoked for years No, but I used to smoke I smoked for years No, I have never smoked Do you now, or have you ever used drugs? Recreational Cocaine Marijuana Has anyone in your immediate family ever had any of the following? Circle the illness that apply. None known Cancer Leukemia Stroke Hypertension Coronary artery disease Rheumatic fever Diabetes (I) (J) (K) (L) (M) (N) (0) (P) Hypothyroidism Colitis Bleeding tendency Asthma Tuberculosis Seizure disorder Alcoholism Have you ever had a blood clot? Yes No
8 Circle any surgeries listed below you may have had. Indicate the year of the surgery: No previous surgeries Hysterectomy Appendectomy Lumbar laminectomy Cataract extraction (I) Mastectomy By-pass I open heart Gall bladder (J) (K) Tonsillectomy Prostate surgery Hernia repair (L) Any previous broken bones: Blood transfusion: Yes /No Year: What medications are you currently taking? Please include both prescription and non-prescription medications. Medications Dose # Times a Day Please provide your Pharmacy information: Name: Phone#: Pharmacy Address/Location: Would you like your medication sent to your Pharmacy electronically? Yes No Please circle any anti-inflammatory medications listed below which you have taken in the past. Please include all prescription and non-prescription medication and samples, which were provided. Advil Arthrotec Daypro Ibuprofen Lodine Naprelan Naproxen Oruvail Tylenol Ultram Other: Please circle any of the following side effects while you were currently taking any of the above anti-inflammatory medications. Nausea Diarrhea Gastric Ulcers Upset stomach Vomiting Other: Are you currently taking any of the following on a regular basis? Aspirin Axid Coumadin Cytotec Heparin Maalox Mylanta Pepcid Prevacid Prilosec Tagamet Zantac
9 TELL US ABOUT YOUR HEALTH IN GENERAL: Do you have any of the following? Circle YES or NO. SYMPTOMS Chest Pain Yes No Dizziness Yes No Dry cough Yes No Productive cough Yes No Difficulty breathing Yes No COMMENTS Irregular heartbeat Yes No Swelling in the legs Yes No Lack of appetite Yes No Nausea Yes No Vomiting Yes No Diarrhea Yes No Constipation Yes No Abdominal cramping Yes No Varicose veins Yes No Bruising Yes No Bleeding Yes No Nose bleeds Yes No Joint pain and/or stiffness Yes No Muscle pain or muscle cramps Yes No Difficulty seeing Yes No Difficulty hearing Yes No Difficulty swallowing Yes No Difficulty sleeping Yes No Everything I have answered is true and correct to the best of my knowledge. Patient Signature THANK YOU FOR COMPLETING THIS PATIENT QUESTIONNAIRE. IT WILL BECOME A PART OF YOUR PERMANENT MEDICAL RECORD AT FLORIDA ORTHOPAEDIC INSTITUTE
Florida Orthopaedic Institute Urgent Care
Date: Florida Orthopaedic Institute Urgent Care Patient Questionnaire Initial Evaluation Patient Name: MR# (Office Use only): Family/Primary Doctor: Phone: Family/ Primary Doctor Address: Who referred
Florida Orthopaedic Institute Urgent Care
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