12-item version, self-administered

This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.

Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please circle only one response.

In the past 30 days, how much difficulty did you have in:

S1. Standing for long periods such as 30 minutes?*

S2. Taking care of your household responsibilities?*

S3. Learning a new task, for example, learning how to get to a new place?*

S4. How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?*

S5. How much have you been emotionally affected by your health problems?*

S6. Concentrating on doing something for ten minutes?*

S7. Walking a long distance such as a kilometre [or equivalent]?*

S8. Washing your whole body?*

S9. Getting dressed?*

S10. Dealing with people you do not know?*

S11. Maintaining a friendship?*

S12. Your day-to-day work?*

H1. Overall, in the past 30 days, how many days were these difficulties present?

Record number of days*

H2. n the past 30 days, for how many days were you totally unableto carry out your usual activities or work because of any health condition?

Record number of days*

H3. In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?

Record number of days*

Patient Name*

Date*

WHODAS Form

12-item version, self-administered

Schedule a free consultation call 612-886-6112

WHODAS Form

12-item version, self-administered

Schedule a free consultation call 612-886-6112

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Call 612-886-6112 to make an appointment.