Upper Extremity Functional Index

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

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* 2. Who is your Physiotherapist?

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* 3. 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
Your usual hobbies, re creational or sporting activities
Lifting a bag of groceries to waist level
Lifting a bag of groceries above your head
Grooming your hair
Pushing up on your hands (eg from bathtub or chair)
Preparing food (eg peeling, cutting)
Driving
Vacuuming, sweeping or raking
Dressing
Doing up buttoms
Using tools or appliances
Opening doors
Cleaning
Tying or lacing shoes
Sleeping
Laundering clothes (eg washing, ironing, folding)
Opening a jar
Throwing a ball
Carrying a small suitcase with your affected limb

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* 4. 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.

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