Upper Extremity Form

Upper Extremity Functional Scale 

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 check an answer for each activity. 

Today, do you or would you have any difficulty at all with: 

Any of your usual work, household, or school activities:
Your usual hobbies, recreational 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 (e.g., from bathtub or chair):
Preparing food (e.g., peeling, cutting):
Driving:
Vacuuming, Sweeping, or Raking:
Dressing:
Doing Up Buttons:
Using Tools or Appliances:
Opening Doors:
Cleaning:
Tying or Lacing Shoes:
Sleeping:
Laundering Clothes (e.g., washing, ironing, folding):
Opening A Jar:
Throwing A Ball:
Carrying a Small Suitcase with your Affected Limb:

Thank you for taking the time to fill out this form.

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Office Hours

Our Regular Schedule

Arlington Chiropractic

Monday:

9:00 am-7:00 pm

Tuesday:

8:30 am-7:00 pm

Wednesday:

9:00 am-7:00 pm

Thursday:

9:00 am-7:00 pm

Friday:

8:00 am-5:00 pm

Saturday:

8:00 am-1:00 pm

Sunday:

Closed