1. Right now, my hand and arm appear to be fine. | 6. I am concerned about the appearance of my arm scar. |
(1) Yes | (0) No scar at all |
(2) No | (1) No concern |
2. I feel pain in my arm or hand. | (2) Trivial concern |
(1) No pain at all | (3) Mild |
(2) Trivial | (4) Moderate |
(3) Mild | (5) Quite concerned |
(4) Moderate | (6) Very concerned |
(5) Quite severe | (7) Extremely concerned |
(6) Severe | 7. My arm has a scar that causes discomfort. |
(7) Severe, unbearable pain | (0) No scar at all |
2. I feel numbness in my arm or hand. | (1) No discomfort |
(1) No numbness at all | (2) Trivial discomfort |
(2) Trivial | (3) Mild |
(3) Mild | (4) Moderate |
(4) Mode rate | (5) Quite uncomfortable |
(5) Quite severe | (6) Very uncomfortable |
(6) Severe | (7) Extremely uncomfortable |
(7) Severe, unbearable numbness | 8. I have difficulties with daily tasks because of the use of my hand and arm. |
4. My arm or hand is swollen. | (1) No difficulties at all |
(1) No swelling at all | (2) Trivial difficulties |
(2) Trivial | (3) Mild |
(3) Mild | (4) Moderate |
(4) Moderate | (5) Quite marked |
(5) Quite severe | (6) Very marked |
(6) Severe | (7) Extremely marked |
(7) Severe, unbearable swelling | Comments: ______________________ |
5. I have limited use of my hand. | 9. Overall, my life is affected by the problems with my hand or arm. |
(1) No limitations at all | (1) No worse at all |
(2) Trivial | (2) Trivial life disruptions |
(3) Mild | (3) Mild |
(4) Moderate | (4) Moderate |
(5) Quite severe | (5) Quite marked |
(6) Severe | (6) Marked |
(7) Extremely limited use | (7) Life radically worse |
Comments: ______________________ |