Upper Extremity Functional Scale Name *
E-Mail *
Physical Therapist * Michael Zazzali DSc.PT OCS Stuart Yeh PT
Instructions
We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your upper limb problem for which you are currently seeking attention. Please provide an answer for each activity.
Today, do you or would you have any difficulty at all with:
1. Any of your usual work, housework, or school activities * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
2. Your usual hobbies, re creational or sporting activities * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
3. Lifting a bag of groceries to waist level * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
4. Lifting a bag of groceries above your head * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
5. Grooming your hair * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
6. Pushing up on your hands (eg from bathtub or chair) * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
7. Preparing food (eg peeling, cutting) * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
8. Driving * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
9. Vacuuming, sweeping or raking * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
10. Dressing * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
11. Doing up buttons * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
12. Using tools or appliances * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
13. Opening doors * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
14. Cleaning * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
15. Tying or lacing shoes * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
16. Sleeping * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
17. Laundering clothes (eg washing, ironing, folding) * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
18. Opening a jar * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
19. Throwing a ball * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
20. Carrying a small suitcase with your affected limb * 0. Extreme Difficulty or Unable to Perform Activity 1. Quite a Bit of Difficulty 2. Moderate Difficulty 3. A Little Bit of Difficulty 4. No Difficulty
