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ULFI-10 CHART

ULFI-10 ASSESSMENT FORM

PLEASE COMPLETE ALL 4 PARTS- Each part has a separate score:

Your upper limb (arm) may make it difficult to do some things you normally do. This list contains sentences people use to describe themselves when they have such problems. Think of yourself over the last few days. If an item describes you mark the box. If not leave the box blank. If an item partly describes you Use a Half (1/2) mark.

 

PART 1

1. I avoid heavy jobs e.g. cleaning, lifting more than 5kg or 10lbs, gardening etc.
2. I have the pain I problem almost all the time
3. I have difficulty with normal home or family duties and chores.
5. I need assistance with personal care e.g. washing and hygiene.
4. I sleep less well.
6. My regular daily activities (work, social contact) are affected.
7. I have difficulty putting my arm into a shirt sleeves or need assistance dressing
8. I have difficulty eating and /or using utensils (e.g. knife, fork, spoon, chop sticks)
9. I use the other arm more often.
10. I have difficulty with buttons, keys, coins, taps/faucets, containers or screw-top lids.

 ULFI SCORE: To Score the Upper Part - Add the Marked Boxes:

 

 

ULFI SCORE: To Score the Upper Part - Add the Marked Boxes:

MDC (90% Confidence): 8.5 % or 0.85 ULFI points. Change less than this may be due to error

MDC (90% Confidence): 8.5 % or 0.85 ULFI points. Change less than this may be due to error

 

PART 2

Think of 5 activities important to you and affected by your arm problem. If you cannot think of 5 then choose from those you have marked above. Score each activity on a scale of 0 - 10 as follows: 0 = WORST: Always affected I Can't do activity at all 10 = BEST: Never affected I Can do activity normally.

PART 3