This questionnaire asks about difficulties due to healthimental 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 m response.
: Only
Numeric scores assigned to each of the items: 4' ; ' 1 I 1 l 3 i 4 l1. 5 g c m z . _ u, ._
In the last 30 days, how much difficulty did you have in: g E i E § g g E . . . ‘ . a . Extreme or 01.1 Concegtgtmg on doung something for ten minutes? None Mlld Moderate Severe cannot do — 01.2 Remembering to do imgortant things? None Mild Moderate Severe :33“;
D13 . m all“ 0 ‘ems j‘ av None Mild Moderate Severe Extreme or e ay life? a cannot do i
Learnin a new task for xam le, le ' how t 30 5 01.4 e p ammg 0 None Mild Moderate Severe Extreme or get to a new place? cannot do
D13 neral und n in what people say? None Mild Moderate Severe 2mm” °' 01.6 Starting and maintaining a conversation? None Mild Moderate Severe :33; . . . - . Extreme or 02.1 Standing for long periods, §UCh as 30 minutes?‘ None Mlld Moderate Severe mm do . t . _ Extreme or 02.2 Standing ug from Slttlng down? None Mlld Moderate Severe cannot do
D23 Moving around inside your home? None Mild Moderate Severe Emma °r _._. .— .. cannot do 25 5
D2.4 Getting out Of your home? None Mild Moderate Severe :3?er
W “ti 3 lo ce such as a kilom r r
D2.5 . ate (0 None Mild Moderate Severe Extreme or
Fquwalem)? cannot do s . 7‘ ‘ Extreme Of 03.1 nghlng your whole body? None Mild Moderate Severe cannot do 03.2 Getting dressed? None Mild Moderate Severe “'3'“ °' . Extreme or 20 5
D33 Eggs? None Mild Moderate Severe cannot do . . Extreme or 03.4 Staying by yourself for a few days? None Mlld Moderate Severe cannot do
Getting along with people . t Extreme or 04.1 9:31!th with people ou do not know? None Mild Moderate Seven cannot do . . . l . Extreme Of
D4.2 Maintaining a friendshlg. None Mlld Moderate Severe cannot do . . . Extreme or
D43 Gefimg along wuth people who are close to you? None Mlld Moderate Severe “mm do —-25 —5
D4i4 Making new friends. None Mlld Moderate Severe cannot do . . . Extreme or 04.5 Sexual actrvltles. None Mlld Moderate Severe cannot do
Only .
Numeric scores assigned to each of the items: I 1 I 2 l 3 l 4 l 5 E c w c
In the last 30 days how much difficulty did you have in: g g E fig g E g
DS.1 Taking care of your hgusghglg responsibilities? ., None M Mlld Moderate Severe mm“ °' ; . « cannot do .u ,
DSTZ Doing most important household tasks well? None Mild Moderate Severe 2:39er ” _