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.
  • Name*full name
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  • Email*a valid email address
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  • Today, do you or would you have any difficulty at all with:*Extreme difficulty or unable to perform activityQuite a bit of difficultyModerate difficultyA little bit of difficultyNo difficulty
    1. Any of your usual work, housework or school activities
    2. Your usual hobbies, recreational or sporting activities.
    3. Lifting a bag of groceries to waist Level
    4. Lifting a bag of groceries to waist Level
    5. Grooming your hair
    6. Pushing up on your hands (eg, from bathtub or chair)
    7. Preparing food (eg, peeling, cutting)
    8. Driving
    9. Vacuuming, sweeping or raking
    10. Dressing
    11. Doing up buttons
    12. Using tools or appliances
    13. Opening doors
    14.Cleaning
    15. Tying or lacing shoes
    16.Sleeping
    17. Laundering clothes (eg, washing, ironing, folding)
    18. Opening a jar
    19. Throwing a ball.
    20. Carrying a small suitcase with your affected limb
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