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Health Assessment Questionnaire (Page 1)
In this section we are interested in learning how your illness affects your ability to function in daily life.
Please check the response which best describes your usual abilities OVER THE PAST WEEK:
Without ANY
Difficulty
With SOME
Difficulty
With MUCH
Difficulty
UNABLE
To Do
DRESSING & GROOMING
Are you able to:
- Dress yourself, including tying shoelaces and doing buttons?
- Shampoo your hair?
ARISING
Are you able to:
- Stand up from a straight chair?
- Get in and out of bed?
EATING
Are you able to:
- Cut your meat?
- Lift a full cup or glass to your mouth?
- Open a new milk carton?
WALKING
Are you able to:
- Walk outdoors on flat ground?
- Climb up five steps?
Please check any AIDS OR DEVICES that you usually use for any of these activities:
Cane
Devices used for dressing (button hook, zipper pull,
long-handled shoe horn, etc.)
Walker
Built up or special utensils
Crutches
Special or built up chair
Wheelchair
Other
(Specify:)
Please check any categories for which you usually need HELP FROM ANOTHER PERSON:
Dressing and Grooming
Eating
Arising
Walking