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 *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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Brain, Not Bone Alone

Get in Touch

Email:

[email protected]

Address:
26302 La Paz Road, Suite 214

Mission Viejo, CA 92691

Phone Number:

Call Office : 949-359-8385

Text Office: 949-619-6545

Hours of Operation

Monday | 9:00am – 5:30pm

Tuesday | 9:00am – 5:30pm

Wednesday | 7:30am – 11:30am

Thursday | 9:00am – 5:30pm

Friday | Closed

Sat & Sun | Closed

26302 La Paz Road, Suite 214

Mission Viejo, CA 92691

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