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Patient Name:
Date of Birth:
Please select the one best answer for your abilities at this time:
Dress yourself, including tying shoelaces and doing buttons?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Get in and out of Bed?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Lift a full cup or glass to your mouth?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Walk outdoors on flat ground?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Bend down to pick up clothing from the floor?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Turn regular faucets on and off?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Get in and out of a car, bus, train or airplane?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Walk two miles or three kilometers, if you wish?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Participate in recreational activities and sports as you would like, if you wish?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Get a good night's sleep?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Deal with feeling of anxiety or being nervous?
Without ANY difficulty (0)
With SOME difficulty (1)
With MUCH difficulty (2)
UNABLE to do (3)
Considering all the ways in which illness and health conditions may affect you at this time please indicate how you are doing (0 = very well, 10 = very poorly)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10