The Upper Extremity Index

Full Name *

Date *

We are interested in knowing whether you are having difficulty at all with the activities listed below because of your upper limb problem for which you are currently seeking treatment. Use the following scale to choose the most appropriate number for each situation.

4 - Extreme

3 - Quite a bit

2 - Moderate

1 - A little bit

0 - None

1. Your usual house work or school activities *

2. Your usual hobbies, recreational or sporting activities *

3. Lifting a bag of groceries to waist level *

4. Lifting a bag of groceries above your head *

5. Grooming your hair *

6. Pushing down on your hands (i.e. from bathtub or chair) *

7. Preparing food ( i.e. peeling or cutting) *

8. Driving *

9. Vacuuming, sweeping or raking *

10. Dressing *

11. Buttoning shirt *

12. Using tools or appliances *

13. Opening doors *

14. Cleaning *

15. Tying shoes *

16. Sleeping *

17. Laundering clothes (i.e. washing, ironing, folding) *

18. Opening a jar *

19. Throwing a ball *

20. Carrying a small suitcase with affected limb *

Captcha

Brain, Not Bone Alone