| Question | Response |
|---|---|
| Date of assessment | |
| Dress yourself, including tying shoelaces and doing buttons? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Shampoo your hair? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Stand up from an armless chair? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Get in and out of bed? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Cut up your own meat? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Lift a full cup or glass to your mouth? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Open a new carton of milk (or soap powder)? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Walk outdoors on flat ground? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Climb up five steps? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Devices used for Dressing (button hook, zipper pull, shoe horn)? | Yes No |
| Cane (W) | Yes No |
| Walking Frame (W) | Yes No |
| Crutches (W) | Yes No |
| Wheel Chair (W) | Yes No |
| Special or built up chair (A) | Yes No |
| Built up or special utensils (E) | Yes No |
| Any other devices used? | Yes No |
| Specify if any other device is used | |
| Dressing and Grooming | Yes No |
| Arising | Yes No |
| Eating | Yes No |
| Walking | Yes No |
| Wash and dry your entire body? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Take a bath? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Get on and off the toilet? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Reach and get down a 5 lb object (e.g. a bag of potatoes) from just above your head? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Bend down to pick up clothing off the floor? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Open car doors? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Open jars which have been previously opened? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Turn taps on and off? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Run errands and shop? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Get in and out of a car? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Do chores such as vacuuming, housework or light gardening? | Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do |
| Raised toilet seat (H) | Yes No |
| Bath seat (H) | Yes No |
| Bath rail (H) | Yes No |
| Long-handled appliances for reach (R) | Yes No |
| Jar opener (for jars previously opened) (G) | Yes No |
| Hygiene | Yes No |
| Reach | Yes No |
| Gripping and opening things | Yes No |
| Errands or housework | Yes No |
| how well you are doing on a scale of 0 to 100 (0 represents ?very well? and 100 represents ?very poor? health) | |
| How much pain have you had IN THE PAST WEEK? On a scale of 0 to 100 (where zero represents ?no pain? and 100 represents ?severe pain?) |