| Question | Response |
|---|---|
| Date Collected | |
| Perfomed | Yes No |
| Reason if not performed | |
| Mobility | I have no problems walking I have slight problems walking I have moderate problems walking I have severe problems walking I am unable to walk |
| Self-care | I have no problems washing or dressing myself I have slight problems washing or dressing myself I have moderate problems washing or dressing myself I have severe problems washing or dressing myself I am unable to wash or dress myself |
| Usual activities | I have no problems doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities |
| Pain/Discomfort | I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort |
| Anxiety/Depression | I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed |
| Health state Visual Analog Score |