Patient-rated elbow evaluation
Total PAIN Score : 0 / 60 = 0.0%
Total FUNCTION Score : 0 / 100 = 0.0%
Total USUAL Score : 0 / 40 = 0.0%
Total Score : 0 / 200 = 0.0%

1. PAIN

Rate the average amount of pain in your elbow over the past week by choosing the number that best describes your pain on a scale from 0-10. A 0 means that you did not have any pain and a ten means that you had the worst pain pain you have ever experienced. Rate your pain:
1. When it is at its worst
0 - Never10 - Always00 - Never48
2. At rest
0 - Never10 - Always00 - Never48
3. When lifting a heavy object
0 - Never10 - Always00 - Never48
4. When doing a task with repeated elbow movement
0 - Never10 - Always00 - Never48
5. How often do you have pain?
0 - Never10 - Always00 - Never48

2. FUNCTION

Rate the amount of difficulty you expreienced performing each of the items listed below, over the past week, by choosing the number that best describes your difficulty on a scale of 0-10. A zero (0) means you did not experience any difficulty and a ten (10) means it was so difficult you were unable to do it at all
6. Comb my hair
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
7. Eat with a fork or spoon
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
8. Pull a heavy object
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
9. Use my arm to rise from a chair
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
10. Carry a 10lb object with my arm at my side
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
11. Throw a small object, such as tennis ball
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
12. Use a telephone
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
13. Do up buttons on the front of my shirt
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
14. Wash my opposite armpit
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
15. Tie my shoe
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
16. Turn the doorknob and open a door
0 - No Difficulty10 - Unable To Do00 - No Difficulty48

3. USUAL ACTIVITIES

Rate the amount of difficulty you exprienced performing your usual activities in each of the areas listed below, over the past week, by choosing the number that best describes your difficulty on a scale of 0-10. By "usual activities", we mean the activities that you performed before you started having a problem with your elbow. A zero (0) means you did not experience any difficulty and a ten (10) means it was so difficult you were unable to do any of your usual activities
17. Personal activities (dressing, washing)
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
18. Household work (cleaning, maintenance)
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
19. Work (your job or every day work)
0 - No Difficulty10 - Unable To Do00 - No Difficulty48
20. Recreational activities
0 - No Difficulty10 - Unable To Do00 - No Difficulty48

Bibliographic References (copyright belongs to the author/s of this instrument)

1. Dowrick AS, Gabbe BJ, Williamson OD, Cameron PA (2005) Outcome instruments for the assessment of the upper extremity following trauma: a review. Injury, 36, 468–476.
2. MacDermid JC (2001) Outcome evaluation in patients with elbow pathology: issues in instrument development and evaluation. J Hand Ther, 14, 105–114.
3. MacDermid JC, Michlovitz SL (2006) Examination of the elbow: linking diagnosis, prognosis, and outcomes as a framework for maximizing therapy interventions. J Hand Ther, 19, 82–97
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