Extreme In the past 30 days, how much None Mild Moderate Severe or cannot difficulty have you had in: do Standing for long periods such as 1 2 3 4 5 30 minutes? Taking care of your household 1 2 3 4 5 responsibilities? Learning a new task, for example, learning how to get to a new 1 2 3 4 5 place or cooking a new recipe? How much of a problem did you have joining in community activities (for example, festivities, 1 2 3 4 5 religious or other activities) in the same way as anyone else can? How much have you been emotionally affected by your 1 2 3 4 5 health problems? In the past 30 days, how much Extreme or None Mild Moderate Severe difficulty have you had in: cannot do Concentrating on doing 1 2 3 4 5 something for ten minutes? Walking a long distance such 1 2 3 4 5 as a kilometre [or equivalent]? Washing your whole body? 1 2 3 4 5 Getting dressed? 1 2 3 4 5 Dealing with people you do 1 2 3 4 5 not know? Maintaining a friendship? 1 2 3 4 5 Your day-to-day 1 2 3 4 5 work/studying? Record number of days: Overall, in the past 30 days, how many days were these difficulties present? Record number of days: 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? Record number of days: 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? Yes If someone of the same age and health as you were to have No the operation you had, would you recommend it? Don’t know
In the past 30 days, how much difficulty have you had in: None Mild Moderate Severe Extreme or cannot do Standing for long periods such as 30 minutes? 1 2 3 4 5 Taking care of your household responsibilities? 1 2 3 4 5 Learning a new task, for example, learning how to get to a new place or cooking a new recipe? 1 2 3 4 5 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? 1 2 3 4 5 How much have you been emotionally affected by your health problems? 1 2 3 4 5 In the past 30 days, how much difficulty have you had in: None Mild Moderate Severe Extreme or cannot do Concentrating on doing something for ten minutes? 1 2 3 4 5 Walking a long distance such as a kilometre [or equivalent]? 1 2 3 4 5 Washing your whole body? 1 2 3 4 5 Getting dressed? 1 2 3 4 5 Dealing with people you do not know? 1 2 3 4 5 Maintaining a friendship? 1 2 3 4 5 Your day-to-day work/studying? 1 2 3 4 5 Overall, in the past 30 days, how many days were these difficulties present? Record number of days: 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? Record number of days: 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: If someone of the same age and health as you were to have the operation you had, would you recommend it? Yes No Don’t know