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Upper Extremity Functional Scale Assessment

This document is a patient assessment form called the Upper Extremity Functional Scale. It contains a list of daily activities and asks patients to rate the level of difficulty they experience in each activity due to their upper limb problem, from 0 (extreme difficulty/unable) to 4 (no difficulty). The activities cover domains like work, hobbies, lifting, grooming, pushing, preparing food, driving, housework, dressing, using tools/appliances, opening doors, tying shoes, sleeping, chores, and carrying items. Patients' scores are calculated by summing the numbers circled for each activity.

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Riris Winchester
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497 views1 page

Upper Extremity Functional Scale Assessment

This document is a patient assessment form called the Upper Extremity Functional Scale. It contains a list of daily activities and asks patients to rate the level of difficulty they experience in each activity due to their upper limb problem, from 0 (extreme difficulty/unable) to 4 (no difficulty). The activities cover domains like work, hobbies, lifting, grooming, pushing, preparing food, driving, housework, dressing, using tools/appliances, opening doors, tying shoes, sleeping, chores, and carrying items. Patients' scores are calculated by summing the numbers circled for each activity.

Uploaded by

Riris Winchester
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Name ____________________________________ Date ________________ Patient ID#_______________

Upper Extremity Functional Scale


We are interested in knowing whether you are having any difficulty with the activities listed below
because of your upper limb problem for which you are currently seeking attention. Provide an answer
for each activity.
Today, do you or would you have any difficulty with: (Circle one number on each line)

Extreme
Difficulty Quite a A Little
or Unable Bit of Moderate Bit of No
to Perform Difficulty Difficulty Difficulty Difficulty
Activities Activity
a. Any of your usual work, household, or 0 1 2 3 4
school activities.
b. Your usual hobbies, recreational or 0 1 2 3 4
sporting activities.
c. Lifting a bag of groceries to waist level. 0 1 2 3 4
d. Lifting a bag of groceries above your head. 0 1 2 3 4
e. Grooming your hair. 0 1 2 3 4
f. Pushing up on your hands (e.g., from 0 1 2 3 4
bathtub or chair).
g. Preparing food (e.g., peeling, cutting). 0 1 2 3 4
h. Driving. 0 1 2 3 4
i. Vacuuming, sweeping, or raking. 0 1 2 3 4
j. Dressing. 0 1 2 3 4
k. Doing up buttons. 0 1 2 3 4
l. Using tools or appliances. 0 1 2 3 4
m. Opening doors. 0 1 2 3 4
n. Cleaning. 0 1 2 3 4
o. Tying or lacing shoes. 0 1 2 3 4
p. Sleeping. 0 1 2 3 4
q. Laundering clothes (e.g., washing, ironing, 0 1 2 3 4
folding).
r. Opening a jar. 0 1 2 3 4
s. Throwing a ball. 0 1 2 3 4
t. Carrying a small suitcase with your 0 1 2 3 4
affected limb).

COLUMN TOTALS (for physical therapist use)

Score is the sum of all circled items. (range = 0-80) Score: _/80

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