Upper extremity functional index

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: (select one number on each line)

Name *
Name
Phone *
Phone
Activities
A. Any of your usual work, house work or school activities. *
B. Your usual hobbies, recreational or sporting activities. *
C. Lifting a bag of groceries to waist level *
D. Lifting a bag of groceries above your head *
E. Grooming your hair *
F. Pushing up on your hands (e.g. from bathtub or chair) *
G. Preparing food (e.g. peeling, cutting) *
H. Driving *
I. Vacuuming, sweeping, or raking *
J. Dressing *
K. Doing up buttons *
L. Using tools or appliances *
M. Opening doors *
N. Cleaning *
O. Tying or lacing shoes *
P. Sleeping *
Q. Laundering clothes (e.g. washing, ironing, folding) *
R. Opening a jar *
S. Throwing a ball *
T. Carrying a small suitcase with your affected limb *

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: (Circle one number on each line)