Domain 1: For each question, place an "X" in the box that best indicates how much difficulty you have experienced in doing the following activities during the past 7 days. If you did not perform a particular activity in the last 7 days, rate the difficulty for the last time you performed the activity. If you can't perform an activity, check the last box. | |||
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Brush or comb your hair | No difficulty | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very difficult |
Walk continuously for 20 minutes | No difficulty | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very difficult |
Prepare a homemade meal | No difficulty | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very difficult |
Vacuum, scrub or sweep floors | No difficulty | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very difficult |
Lift and carry a bag full of groceries | No difficulty | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very difficult |
Climb one flight of stairs | No difficulty | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very difficult |
Change bed sheets | No difficulty | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very difficult |
Sit in a chair for 45 minutes | No difficulty | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very difficult |
Go shopping for groceries | No difficulty | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very difficult |
Domain 2: For each of the following 2 questions, check the one box that best describes the overall impact of any medical problems over the last 7 days. | |||
My medical problems prevented me from accomplishing goals. | Never | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Always |
I was completely overwhelmed by my medical problems | Never | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Always |
Domain 3: For each of the following 10 questions, check the one box that best indicates the intensity of the following common symptoms over the last 7 days. | |||
Please rate your level of pain | No pain | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Unbearable pain |
Please rate your level of energy | Lots of energy | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | No energy |
Please rate your level of stiffness | No stiffness | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Severe stiffness |
Please rate the quality of your sleep | Awoke rested | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Awoke very tired |
Please rate your level of depression | No depression | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very depressed |
Please rate your level of memory problems | Good memory | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very poor memory |
Please rate your level of anxiety | Not anxious | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very anxious |
Please rate your level of tenderness to touch | No tenderness | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Very tender |
Please rate your level of balance problems | No imbalance | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Severe imbalance |
Please rate your level of sensitivity to loud noises, bright lights, odors and cold | No sensitivity | â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ | Extreme sensitivity |