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OCEAN PINES 410-208-3300
SALISBURY 410-742-3300

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SALISBURY 410-742-3300
OCEAN PINES 410-208-3300

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Quick Dash Form

If you prefer not to use our online form, you can hit the button below to open the .pdf and print for your visit.

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Step 1 of 6

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Name*
First Last
Date*
MM slash DD slash YYYY
Phone
Email*

PLEASE READ CAREFULLY: Please rate your ability to do the following activities in the past week
1. 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
2. Do heavy household chores. (e.g., wash walls, floors, etc.)*
- 1. Not Limited At All
- 2. Slightly Limited
- 3. Moderately Limited
- 4. Very Limited
- 5. Unable
3. Carry a shopping bag or briefcase.*
- 1. Not Limited At All
- 2. Slightly Limited
- 3. Moderately Limited
- 4. Very Limited
- 5. Unable

4. Wash your back.*
- 1. Not Limited At All
- 2. Slightly Limited
- 3. Moderately Limited
- 4. Very Limited
- 5. Unable
5. Use your knife to cut food.*
- 1. Not Limited At All
- 2. Slightly Limited
- 3. Moderately Limited
- 4. Very Limited
- 5. Unable
6. Recreational activities in which you take some force or impact through your arm, shoulder or hand. (e.g., golf, hammering, tennis, etc.) 1*
- 1. Not Limited At All
- 2. Slightly Limited
- 3. Moderately Limited
- 4. Very Limited
- 5. Unable
7. 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 At All
- 2. Slightly
- 3. Moderately
- 4. Quite a bit
- 5. Extremely

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?*
- 1. Not Limited At All
- 2. Slightly Limited
- 3. Moderately Limited
- 4. Very Limited
- 5. Unable
9. Arm, shoulder or hand pain.*
- 1. None
- 2. Mild
- 3. Moderate
- 4. Severe
- 5. Extreme
10. Tingling (pins and needles) in your arm, shoulder or hand.*
- 1. None
- 2. Mild
- 3. Moderate
- 4. Severe
- 5. Extreme
11. During the past week, how much difficulty have you had sleeping because of pain in your arm, shoulder or hand? (circle number)*
- 1. No Difficulty
- 2. Mild Difficulty
- 3. Moderate Difficulty
- 4. Severe Difficulty
- 5. So Much Difficulty That I Can’t Sleep

QUICK DASH SCORE
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BERLIN

11007 Manklin Creek Rd, Unit 5
Berlin, MD 21811

Phone Number
410-208-3300

Fax Number
443-513-3958

Call Us: 410-208-3300

SALISBURY

119 West College Ave Suite 205 Salisbury, MD 21804

Phone Number
410-742-3300

Fax Number
410-742-4040

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