UEFI Survey

Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. 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.

	0 Extreme Difficulty or Unable to Perform Activity	1 Quite a Bit of Difficulty	2 Moderate Difficulty	3 A Little Bit of Difficulty	4 No Difficulty
Any of your usual work, housework, or school activities	Any of your usual work, housework, or school activities 0 Extreme Difficulty or Unable to Perform Activity	Any of your usual work, housework, or school activities 1 Quite a Bit of Difficulty	Any of your usual work, housework, or school activities 2 Moderate Difficulty	Any of your usual work, housework, or school activities 3 A Little Bit of Difficulty	Any of your usual work, housework, or school activities 4 No Difficulty
Your usual hobbies, re creational or sporting activities	Your usual hobbies, re creational or sporting activities 0 Extreme Difficulty or Unable to Perform Activity	Your usual hobbies, re creational or sporting activities 1 Quite a Bit of Difficulty	Your usual hobbies, re creational or sporting activities 2 Moderate Difficulty	Your usual hobbies, re creational or sporting activities 3 A Little Bit of Difficulty	Your usual hobbies, re creational or sporting activities 4 No Difficulty
Lifting a bag of groceries to waist level	Lifting a bag of groceries to waist level 0 Extreme Difficulty or Unable to Perform Activity	Lifting a bag of groceries to waist level 1 Quite a Bit of Difficulty	Lifting a bag of groceries to waist level 2 Moderate Difficulty	Lifting a bag of groceries to waist level 3 A Little Bit of Difficulty	Lifting a bag of groceries to waist level 4 No Difficulty
Lifting a bag of groceries above your head	Lifting a bag of groceries above your head 0 Extreme Difficulty or Unable to Perform Activity	Lifting a bag of groceries above your head 1 Quite a Bit of Difficulty	Lifting a bag of groceries above your head 2 Moderate Difficulty	Lifting a bag of groceries above your head 3 A Little Bit of Difficulty	Lifting a bag of groceries above your head 4 No Difficulty
Grooming your hair	Grooming your hair 0 Extreme Difficulty or Unable to Perform Activity	Grooming your hair 1 Quite a Bit of Difficulty	Grooming your hair 2 Moderate Difficulty	Grooming your hair 3 A Little Bit of Difficulty	Grooming your hair 4 No Difficulty
Pushing up on your hands (eg from bathtub or chair)	Pushing up on your hands (eg from bathtub or chair) 0 Extreme Difficulty or Unable to Perform Activity	Pushing up on your hands (eg from bathtub or chair) 1 Quite a Bit of Difficulty	Pushing up on your hands (eg from bathtub or chair) 2 Moderate Difficulty	Pushing up on your hands (eg from bathtub or chair) 3 A Little Bit of Difficulty	Pushing up on your hands (eg from bathtub or chair) 4 No Difficulty
Preparing food (eg peeling, cutting)	Preparing food (eg peeling, cutting) 0 Extreme Difficulty or Unable to Perform Activity	Preparing food (eg peeling, cutting) 1 Quite a Bit of Difficulty	Preparing food (eg peeling, cutting) 2 Moderate Difficulty	Preparing food (eg peeling, cutting) 3 A Little Bit of Difficulty	Preparing food (eg peeling, cutting) 4 No Difficulty
Driving	Driving 0 Extreme Difficulty or Unable to Perform Activity	Driving 1 Quite a Bit of Difficulty	Driving 2 Moderate Difficulty	Driving 3 A Little Bit of Difficulty	Driving 4 No Difficulty
Vacuuming, sweeping or raking	Vacuuming, sweeping or raking 0 Extreme Difficulty or Unable to Perform Activity	Vacuuming, sweeping or raking 1 Quite a Bit of Difficulty	Vacuuming, sweeping or raking 2 Moderate Difficulty	Vacuuming, sweeping or raking 3 A Little Bit of Difficulty	Vacuuming, sweeping or raking 4 No Difficulty
Dressing	Dressing 0 Extreme Difficulty or Unable to Perform Activity	Dressing 1 Quite a Bit of Difficulty	Dressing 2 Moderate Difficulty	Dressing 3 A Little Bit of Difficulty	Dressing 4 No Difficulty
Doing up buttoms	Doing up buttoms 0 Extreme Difficulty or Unable to Perform Activity	Doing up buttoms 1 Quite a Bit of Difficulty	Doing up buttoms 2 Moderate Difficulty	Doing up buttoms 3 A Little Bit of Difficulty	Doing up buttoms 4 No Difficulty
Using tools or appliances	Using tools or appliances 0 Extreme Difficulty or Unable to Perform Activity	Using tools or appliances 1 Quite a Bit of Difficulty	Using tools or appliances 2 Moderate Difficulty	Using tools or appliances 3 A Little Bit of Difficulty	Using tools or appliances 4 No Difficulty
Opening doors	Opening doors 0 Extreme Difficulty or Unable to Perform Activity	Opening doors 1 Quite a Bit of Difficulty	Opening doors 2 Moderate Difficulty	Opening doors 3 A Little Bit of Difficulty	Opening doors 4 No Difficulty
Cleaning	Cleaning 0 Extreme Difficulty or Unable to Perform Activity	Cleaning 1 Quite a Bit of Difficulty	Cleaning 2 Moderate Difficulty	Cleaning 3 A Little Bit of Difficulty	Cleaning 4 No Difficulty
Tying or lacing shoes	Tying or lacing shoes 0 Extreme Difficulty or Unable to Perform Activity	Tying or lacing shoes 1 Quite a Bit of Difficulty	Tying or lacing shoes 2 Moderate Difficulty	Tying or lacing shoes 3 A Little Bit of Difficulty	Tying or lacing shoes 4 No Difficulty
Sleeping	Sleeping 0 Extreme Difficulty or Unable to Perform Activity	Sleeping 1 Quite a Bit of Difficulty	Sleeping 2 Moderate Difficulty	Sleeping 3 A Little Bit of Difficulty	Sleeping 4 No Difficulty
Laundering clothes (eg washing, ironing, folding)	Laundering clothes (eg washing, ironing, folding) 0 Extreme Difficulty or Unable to Perform Activity	Laundering clothes (eg washing, ironing, folding) 1 Quite a Bit of Difficulty	Laundering clothes (eg washing, ironing, folding) 2 Moderate Difficulty	Laundering clothes (eg washing, ironing, folding) 3 A Little Bit of Difficulty	Laundering clothes (eg washing, ironing, folding) 4 No Difficulty
Opening a jar	Opening a jar 0 Extreme Difficulty or Unable to Perform Activity	Opening a jar 1 Quite a Bit of Difficulty	Opening a jar 2 Moderate Difficulty	Opening a jar 3 A Little Bit of Difficulty	Opening a jar 4 No Difficulty
Throwing a ball	Throwing a ball 0 Extreme Difficulty or Unable to Perform Activity	Throwing a ball 1 Quite a Bit of Difficulty	Throwing a ball 2 Moderate Difficulty	Throwing a ball 3 A Little Bit of Difficulty	Throwing a ball 4 No Difficulty
Carrying a small suitcase with your affected limb	Carrying a small suitcase with your affected limb 0 Extreme Difficulty or Unable to Perform Activity	Carrying a small suitcase with your affected limb 1 Quite a Bit of Difficulty	Carrying a small suitcase with your affected limb 2 Moderate Difficulty	Carrying a small suitcase with your affected limb 3 A Little Bit of Difficulty	Carrying a small suitcase with your affected limb 4 No Difficulty

Question Title

* 3. Interpretation of scores (for office use only)

Total score: add up the total scores = _______/80 MCID = Dominant arm = 7, Non-dominant arm = 10 SCORE RANGE = 80(no disability) to 0 (max disability)

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

Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. 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.

Question Title

* 3. Interpretation of scores (for office use only)Total score: add up the total scores = _______/80 MCID = Dominant arm = 7, Non-dominant arm = 10 SCORE RANGE = 80(no disability) to 0 (max disability)

* 3. Interpretation of scores (for office use only)

Total score: add up the total scores = _______/80 MCID = Dominant arm = 7, Non-dominant arm = 10 SCORE RANGE = 80(no disability) to 0 (max disability)