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Form 2 -
Upper limb issue form

Complete this form if you:

  • Have already been to Coogee Bay Physio (if not please complete form 1)

  • Have an issue with your shoulders, neck, arms, arm joints or hands.

About this form:

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.

Your details
Name *
Name
Your main daytime contact number
Questions
1. Today, do you or would you have any difficulty at all with your usual work, housework or school activities? *
2. Today, do you or would you have any difficulty at all with your usual hobbies, recreational or sporting activities? *
3. Today, do you or would you have any difficulty at all with lifting a bag of groceries to waist level? *
4. Today, do you or would you have any difficulty at all with lifting a bag of groceries above your head? *
5. Today, do you or would you have any difficulty at all with grooming your hair? *
6. Today, do you or would you have any difficulty at all with pushing up from your hands (eg from bathtub to chair)? *
7. Today, do you or would you have any difficulty at all with preparing food (eg peeling, cutting)? *
8. Today, do you or would you have any difficulty at all with driving? *
9. Today, do you or would you have any difficulty at all with vacuuming, sweeping or raking? *
10. Today, do you or would you have any difficulty at all with dressing? *
11. Today, do you or would you have any difficulty at all with doing up buttons? *
12. Today, do you or would you have any difficulty at all with using tools or appliances? *
13. Today, do you or would you have any difficulty at all with opening doors? *
14. Today, do you or would you have any difficulty at all with cleaning? *
15. Today, do you or would you have any difficulty at all with tying or lacing shoes? *
16. Today, do you or would you have any difficulty at all with sleeping? *
17. Today, do you or would you have any difficulty at all with laundering clothes (washing, ironing, folding)? *
18. Today, do you or would you have any difficulty at all with opening jar? *
19. Today, do you or would you have any difficulty at all with throwing a ball? *
20. Today, do you or would you have any difficulty at all with carrying a small suitcase with your affected limb? *
Thank you!
Submitting this form will form a valuable part of our ongoing assessment of your functional capacity, your treatment and your recovery.

To discuss further or learn more about our clinic and treatment options please don’t hesitate to get in touch with us by clicking here.

Or, call us on (02) 9665 9667 during business hours.

Index source: Stratford PW, Binkley, JM, Stratford DM (2001): Development and initial validation of the upper extremity functional index. Physiotherapy Canada. 53(4):259-267.