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
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
2. Your usual hobbies, recreational or sporting activities
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
3. Lifting a bag of groceries to waist level
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
4. Lifting a bag of groceries above your head
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
5. Grooming your hair
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
6. Pushing up on your hands (e.g. from bathub or chair)
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
7. Preparing food (e.g. peeling, cutting)
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
8. Driving
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
9. Vacuuming, sweeping, or raking
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
10. Dressing
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
11. Doing up buttons
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
12. Using tools or applicances
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
13. Opening doors
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
14. Cleaning
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
15. Tying or lacing shoes
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
16. Sleeping
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
17. Laundering clothes (e.g. washing, ironing, folding)
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
18. Opening a jar
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
19. Throwing a ball
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
20. Carrying a small suitcase with your affected limb
Extreme Difficulty (0) Quit a Bit of Difficulty (1) Moderate Difficulty (2) A little Bit of Difficulty (3) No Difficulty (4)
Bibliographic References (copyright belongs to the author/s of this instrument)
1. Stratford PW, Binkley, JM, Stratford DM (2001): Development and initial validation of the upper extremity functional index. Physiotherapy Canada. 53(4):259-267.