Personal Growth Better Quality of Life Reduced Stress World Health Org Disability Assessment Schedule Date* Date Format: MM slash DD slash YYYY Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY <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?NoneMildModerateSevereExtreme or cannot do*S2. Taking care of your household responsibilities?NoneMildModerateSevereExtreme or cannot do*S3. Learning a new task, for example, learning how to get to a new place?NoneMildModerateSevereExtreme 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?NoneMildModerateSevereExtreme or cannot do*S5. How much have you been emotionally affected by your health problems?NoneMildModerateSevereExtreme or cannot do*S6. Concentrating on doing something for ten minutes?NoneMildModerateSevereExtreme or cannot do*S7. Walking a long distance such as a kilometer (or equivalent)?NoneMildModerateSevereExtreme or cannot do*S8. Washing your whole body?NoneMildModerateSevereExtreme or cannot do*S9. Getting dressed?NoneMildModerateSevereExtreme or cannot do*S10. Dealing with people you do not know?NoneMildModerateSevereExtreme or cannot do*S11. Maintaining a friendship?NoneMildModerateSevereExtreme or cannot do*S12. Your day-to-day work?NoneMildModerateSevereExtreme or cannot do*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?*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 2.0Untitled<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.
