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Patient-rated Tennis Elbow Evaluation

Name:(Required)
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The questions below will help us understand the amount of difficulty you have had with your arm in the past week. You will be describing your average arm symptoms over the past week on a scale 0-10. Please provide an answer for all questions. If you did not perform an activity because of pain or because you were unable ,then you should circle a “10”. If you are unsure please estimate to the best of your ability. If you do not perform a specific activity, select N/A for that questions.

1. PAIN in your affected arm

Rate the average amount of pain in your arm over the past week by circling the number that best describes your pain on a scale from 0-10. A zero (0) means that you did not have any pain and a ten (10) means that you had the worst pain imaginable.

RATE YOUR PAIN:

012345678910N/A
When your are at rest
When doing a task with repeated arm movement
When carrying a plastic bag of groceries
When your pain was at its least
When your pain was at its worst

2. FUNCTIONAL DISABILITY

A. SPECIFIC ACTIVITIES

Rate the amount of difficulty you experienced performing each of the tasks listed below, over the past week, by circling the number that best describes your difficulty on a scale of 0-10. A zero (0) means you did not experience any difficulty and a ten (10) means it was so difficult you were unable to do it at all.
012345678910N/A
Turn a doorknob or key
Carry a grocery bag or briefcase by the handle
Lift a full coffee cup or glass of milk to your mouth
Open a jar
Pull up pants
Wring out a washcloth or wet towel

B. USUAL ACTIVITIES

Rate the amount of difficulty you experienced performing your usual activities in each of the areas listed below, over the past week, by circling the number that best describes your difficulty on a scale of 0-10. By “usual activities”, we mean the activities that you performed before you started having a problem with your arm. A zero (0) means you did not experience any difficulty and a ten (10) means it was so difficulty you were unable to do any of your usual activities.
012345678910N/A
Turn a doorknob or key
1. Personal activities (dressing, washing)
2. Household work (cleaning, maintenance)
3. Work (your job or everyday work)
4. Recreational or sporting activities

Scoring Instructions



Minimize non-response by checking forms when patients complete them. Make sure that the patient left an item blank because they could not do it, that they understand that should have recorded this item as a “10”. If patients are unsure because they have rarely performed an activity in the past week, then they should be encouraged to estimate their average difficulty. This will be more accurate than leaving it blank. If they never perform an activity they will not be able to estimate and should leave it blank. If items from a subscale are left blank, then you can substitute the average score from that subscale.
Pain Subscale- Add up 5 items. Best score= 0; Worst score =50
Specific Activities- Add up 6 items Best Score= 0; Worst Score = 60
Usual Activities – Add up 4 items items Best Score= 0; Worst Score = 40
Function Subscale- (Specific Activities + Usual Activities)/2 Best score= 0; Worst score =50
Total Score = Pain Subscale + Function Subscale Best Score= 0 Worst Score = 100 (pain and disability contribute equally to score)

Reliability of subscales and total score are sufficiently high that both subscales and total are reportable.

Thank you for completing this questionnaire. It will be sent to your Clinician at Precision Physio.