PASC Elbow Scores (SANE/DASH)
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Please enter the date *
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Last Name *
First Name *
Date of Birth *
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DD
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YYYY
Treating Doctor *
Elbow SANE-F Score *
Enter a number for the current functional level of your elbow.  100% is normal function, 0% is completely disabled
Elbow SANE-I Score
Enter a number for the current % improvement of your elbow compared to before treatment.  100% is completely better, 0% is no improvement
The DASH Elbow Survey should take 10 minutes to fill out.
Which side was treated *
Please do separate surveys if both sides were treated.  Thank you!
Please rate your ability to do the following activities in the last week.
Open a tight or new jar
Write
Turn a key
Prepare a meal
Push open a heavy door
Place an object on a shelf overhead
Do heavy household chores (wash walls and floors)
Do garden or yard work
Make a bed
Carry a shopping bag or briefcase
Carry a heavy object (>10 lbs)
Change a lightbulb overhead
Wash or blowdry your hair
Wash your back
Put on a pullover sweater
Use a knife to cut food
Recreational activities which require little effort (cards, knitting)
Recreational activities which place some force on the elbow (golf, tennis, hammering)
Recreational activities in which you move your arm freely (frisbee, badminton)
Manage transportation needs
Sexual activities
During the past week, to what extent has your elbow problem interfered with your normal social activities with family, friends, neighbors, or groups?
During the past week, were you limited in your work or other daily activities as a result of your elbow problem?
During the past week, rate the severity of your elbow pain
During the past week, rate the severity of your elbow symptoms when you performed and specific activity
During the past week, rate the severity of any tingling around or in your elbow
During the past week, rate the severity of any weakness around or in your elbow
During the past week, rate the severity of any stiffness around or in your elbow
During the past week, how much difficulty have you had sleeping because of elbow pain?
I feel less capable, less or less useful because of my elbow...
DASH Scoring (for PASC staff use only)   (Sum of responses/30 - 1)x 25 = DASH (100 point scale)  higher score = greater disability
 DASH SCORE (PASC STAFF USE ONLY)
If you play a sport or musical instrument please complete the next 4 questions (Sports/Arts Module)  If not, please skip to the Work Module below
During the past week did you have any difficulty with  your usual technique?
Clear selection
During the past week did you have any difficulty playing because of your elbow pain?
Clear selection
During the past week did you have any difficulty playing as well as you would like?
Clear selection
During the past week did you have any difficulty spending your usual amount of time in practice or playing?
Clear selection
DASH Sports/Arts Module Scoring (for PASC staff use only)   (Sum of responses/4 - 1)x 25 = DASH (100 point scale)  higher score = greater disability
SPORTS/ARTS DASH SCORE                                (PASC STAFF USE ONLY)
If you work please complete the next 4 questions (Work Module)  If not, you are finished and please click the submit button at the bottom of the page.  Thank You!
During the past week did you have any difficulty with  your usual technique for work?
Clear selection
During the past week did you have any difficulty doing your job because of your elbow pain?
Clear selection
During the past week did you have any difficulty doing your job as well as you would like?
Clear selection
During the past week did you have any difficulty spending your usual amount of time doing your work?
Clear selection
DASH Work Module Scoring (for PASC staff use only)   (Sum of responses/4 - 1)x 25 = DASH (100 point scale)  higher score = greater disability
WORK DASH SCORE      (PASC STAFF USE ONLY)
Thank you for completing the DASH Elbow Survey!
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