Personal Growth Better Quality of Life Reduced Stress World Health Org Disability Assessment Schedule Date* MM slash DD slash YYYY Name* First Last Date of Birth* MM slash DD slash YYYY Hidden<br>This questionnaire asks about <u>difficulties due to health conditions</u>. 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.<br><br>Think back over the past <u>30 days</u> and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please circle only <u>one</u> response. <br><br>In the past 30 days, how much difficulty did you have in:<br><br>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?*S1. Standing for long periods such as 30 minutes? None Mild Moderate Severe Extreme or cannot do S2. Taking care of your household responsibilities?*S2. Taking care of your household responsibilities? None Mild Moderate Severe Extreme or cannot do S3. Learning a new task, for example, learning how to get to a new place?*S3. Learning a new task, for example, learning how to get to a new place? None Mild Moderate Severe Extreme or cannot do 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?*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? None Mild Moderate Severe Extreme or cannot do S5. How much have you been emotionally affected by your health problems?*S5. How much have you been emotionally affected by your health problems? None Mild Moderate Severe Extreme or cannot do S6. Concentrating on doing something for ten minutes?*S6. Concentrating on doing something for ten minutes? None Mild Moderate Severe Extreme or cannot do S7. Walking a long distance such as a kilometer (or equivalent)?*S7. Walking a long distance such as a kilometer (or equivalent)? None Mild Moderate Severe Extreme or cannot do S8. Washing your whole body?*S8. Washing your whole body? None Mild Moderate Severe Extreme or cannot do S9. Getting dressed?*S9. Getting dressed? None Mild Moderate Severe Extreme or cannot do S10. Dealing with people you do not know?*S10. Dealing with people you do not know? None Mild Moderate Severe Extreme or cannot do S11. Maintaining a friendship?*S11. Maintaining a friendship? None Mild Moderate Severe Extreme or cannot do S12. Your day-to-day work?*S12. Your day-to-day work? None Mild Moderate Severe Extreme or cannot do H1. Overall, in the past 30 days, how many days were these difficulties present?*H1. Overall, in the past 30 days, how many days were these difficulties present?H2. In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?*H2. In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?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?*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?WHODAS 2.0 (12-Self-administered) World Health Organization Disability Assessment Schedule 2.0HiddenUntitled<div style="font-size:12px">WHODAS 2.0 (12-Self-administered) World Health Organization Disability Assessment Schedule 2.0</div>PhoneThis field is for validation purposes and should be left unchanged.
