DISABILITY ASSESSMENT SCHEDULE

(1)

WORLD HEALTH ORGANIZATION

DISABILITY ASSESSMENT SCHEDULE

WHODAS II

Phase 2 Field Trials – Health Services Research 12 +24 Interviewer Administered, Days Version

February 2000

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2

This instrument was developed by the WHO’s Assessment, Classification and Epidemiology Group within the framework of the WHO/NIH Joint Project on Assessment and Classification of

Disablements. The International Task Force members who contributed to the development of this instrument include:

Elizabeth Badley Canada Ron Kessler USA

Karen Ritchie France Robert Trotter USA

Srinivasa Murthy India Michael Von Korff USA

Charles Pull Luxembourg Robert Battjes NIDA

Hans Hoek Netherlands Bennett Fletcher NIDA

Durk Wiersma Netherlands Bridget Grant NIAAA

Martin Prince UK Cille Kennedy NIMH

The WHO team:

Somnath Chatterji Jayne Lux Shekhar Saxena Patrick Doyle Christopher Nelson T. Bedirhan Üstün JoAnne Epping-Jordan Jurgen Rehm

Matilde Leonardi Ritu Sadana

Field Trial Centers:

Thomas Kugener Austria Hans Hoek Netherlands

Kruy Kim Hourn Cambodia Bisi Odejide Nigeria

Yao Guizhong China José Luis Segura García Peru

Jesús Saíz Cuba Radu Vrasti Romania

Venos Mavreas Greece José Luis Vazquez Barquero Spain Srinivasa Murthy India, Bangalore Adel Chaker Tunisia

Hemraj Pal India, Delhi Berna Ulug Turkey

Ugo Nocentini Italy Martin Prince UK

Miyako Tazaki Japan Ron Kessler USA

Elie Karam Lebanon Katherine McGonagle USA

Charles Pull Luxembourg Michael Von Korff USA

The proper use of this instrument requires appropriate training of interviewers including use of the WHO-DAS II Interviewer’s Training Manual and Interview Guide. The computerized version of the interview (I shell) is available for computer assisted interviews or for data entry. Informant (proxy) and self-administered versions of this instrument are available for field testing.

Permission to translate this instrument into any language should be obtained from WHO. All translations should be prepared according to the WHO translation guidelines.

For additional information, please contact:

Dr T. Bedirhan Üstün Group Leader

Assessment, Classification and Epidemiology Group World Health Organization

CH – 1211 Geneva 27 Switzerland

Tel: + + 41 22 791 3609 Fax: + + 41 22 791 4885 Email: ustunb@who.ch

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SECTION 1. Face Sheet

ITEMS F1- F6 ARE TO BE COMPLETED BY INTERVIEWERS PRIOR TO STARTING EACH INTERVIEW

F1 RESPONDENT I.D . #

CENTRE # - SUBJECT #

F2 INTERVIEWER I.D. #

CENTRE # - INTERVIEWER #

F3 ASSESSMENT TIME POINT (1, 2, ETC.)

F4 INTERVIEW DATE ___ ___/___ ___/___ ___

month day year

F5 LIVING SITUATION AT TIME OF

INTERVIEW (CIRCLE ONLY ONE) Independent in Community 1 Assisted Living 2 Hospitalized 3

F6 SAMPLE (CIRCLE ONLY ONE)

General population 1

Drug related problems 2 Alcohol related problems 3 Mental health problems 4

Physical problems 5

Other (specify) 6

__________________________

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4

SECTION 2. DEMOGRAPHIC AND BACKGROUND INFORMATION

PREAMBLE

This interview has been developed by the World Health Organization to better understand the difficulties people may have due to their health conditions. The information that you provide in this interview is confidential and will be used only for research.

FOR RESPONDENTS FROM THE GENERAL POPULATION (NOT THE CLINICAL POPULATION) SAY: Even if you are healthy and have no difficulties, it is necessary that I ask all of the questions for completeness.

I will begin with some background questions.

A1 RECORD SEX AS OBSERVED Female 1

Male 2

A2 How old are you now? ___/___ years

A3 How many years in all did you spend studying in

school, college or university? ___/___ years

A4 What is your current marital status?

(SELECT THE SINGLE BEST OPTION)

Never married 1

Currently married 2

Separated 3

Divorced 4

Widowed 5

Cohabiting 6

(5)

A5 Which describes your main work status best?

Paid work 1

Self employed, such as own 2 your business or farming Non paid work, such as 3 volunteer or charity

Student 4

Keeping house/Homemaker 5

Retired 6

Unemployed (health reasons) 7 Unemployed (other reasons) 8

Other (specify) 9

__________________________

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6

SECTION 3: PREAMBLE SAY TO RESPONDENT:

The interview is about difficulties people have because of health conditions. (HAND FLASHCARD #1 TO RESPONDENT). By health condition I mean diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems and problems with alcohol or drugs.

I remind you to keep all of your health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about (POINT TO FLASHCARD #1).

• Increased effort

• Discomfort or pain

• Slowness

• Changes in the way you do the activity

(POINT TO FLASHCARD #1). When answering, I’d like you to think back over the last 30 days. I also would like you to answer these questions thinking about how much difficulty you have, on average over the past 30 days, while doing the activity as you usually do it.

(HAND FLASHCARD #2 TO RESPONDENT). Use this scale when responding. (READ SCALE ALOUD): None, mild, moderate, severe, extreme or cannot do.

(FLASHCARDS #1 AND #2 SHOULD REMAIN VISIBLE TO THE RESPONDENT THROUGHOUT THE INTERVIEW. )

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SECTION 4. CORE QUESTIONS SHOW FLASHCARD #2 to participant

In the last 30 days how much difficulty did you have in:

None Mild Moderate Severe

Extreme /Cannot Do

S1 Standing for long periods such as

30 minutes? 1 2 3 4 5

S2 Taking care of your household

responsibilities? 1 2 3 4 5

S3 Learning a new task, for example, learning how to get to a new

place? 1 2 3 4 5

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?

1 2 3 4 5

S5 How much have you been emotionally affected by your

health problems? 1 2 3 4 5

IF ANY OF S1-S5 ARE ENDORSED (RATED GREATER THAN NONE), CONTINUE WITH S6-S12

OTHERWISE, THIS IS THE END OF THE INTERVIEW.

This concludes our interview, thank you for participating.

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8

S6 Concentrating on doing something

for ten minutes? 1 2 3 4 5

S7 Walking a long distance such as a

kilometre [or equivalent]? 1 2 3 4 5

S8 Washing your whole body? 1 2 3 4 5

S9 Getting dressed? 1 2 3 4 5

S10 Dealing with people you do not

know? 1 2 3 4 5

S11 Maintaining a friendship? 1 2 3 4 5

S12 Your day to day work? 1 2 3 4 5

H3 Overall, in the past 30 days, how many days were these difficulties present?

RECORD NUMBER OF DAYS ___/___

CONTINUE BY ADMINISTERING THE SPECIFIED DOMAINS AS FOLLOWS:

IF QUESTION IS ENDORSED (CODED 2-5)

GO TO DOMAIN NUMBER

S3 or S6 1 on page 7

S2 or S12 5 on pages 11-12

S4 or S5 6 on page 13 –14

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DOMAIN 1 Understanding and Communicating

Now I am going to ask some questions about understanding and communicating.

show flashcards #1 AND #2

for responses greater than NONE (1), ASK: how many days was this difficulty present?

RECORD NUMBER OF DAYS (0 - 30)

In the last 30 days, how much difficulty did you have in:

None Mild Moderate Severe

Extreme /Cannot Do

Number Days

D1.2 Remembering to do important

things? 1 2 3 4 5 ^_______

D1.2d

D1.3 Analysing and finding solutions to

problems in day to day life? 1 2 3 4 5 ^_______

D1.3d

D1.5 Generally understanding what people

say? 1 2 3 4 5 ^_______

D1.5d

D1.6 Starting and maintaining a conversation? 1 2 3 4 5 ^_______

D1.6d

Probe:

IF ANY OF D1.1 – D1.6 ARE RATED GREATER THAN NONE (1), ASK:

P1.1 How much did these difficulties interfere

with your life? 1 2 3 4 5

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10 DOMAIN 2 Getting Around

I am now going to ask you about difficulties in getting around.

SHOW FLASHCARDS #1 AND #2

RECORD NUMBER OF DAYS (0-30)

Extreme /Cannot Do

Number Days

D2.2 Standing up from sitting down? 1 2 3 4 5 ^_______

D2.2d

D2.3 Moving around inside your home? 1 2 3 4 5 ^_______

D2.3d

D2.4 Getting out of your home? 1 2 3 4 5 ^_______

D2.4d

Probe:

IF ANY OF D2.1 –D2.5 ARE RATED GREATER THAN NONE (1), ASK:

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DOMAIN 3 Self Care

I am now going to ask you about difficulties in taking care of yourself.

for responses greater than NONE (1), SHOW FLASHCARD #3 ASK: how many days was this difficulty present?

Extreme /Cannot Do

Number Days

D3.3 Eating? 1 2 3 4 5 ^_______

D3.3d

D3.4 Staying by yourself for a few days? 1 2 3 4 5 ^_______^D3.4d

Probe:

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12 DOMAIN 4 Getting along with people

I am now going to ask you about difficulties in getting along with people. Please remember that I am asking only about difficulties that are due to health problems. By this I mean diseases or illnesses, injuries, mental or emotional problems and problems with alcohol or drugs.

for responses greater than NONE (1), SHOW FLASHCARD #3 ASK: how many days was this difficulty present?

Extreme /Cannot Do

Number Days

D4.3 Getting along with people who are close

to you? 1 2 3 4 5 ^_______

D4.3d

D4.4 Making new friends? 1 2 3 4 5 ^_______

D4.4d

D4.5 Sexual activities? 1 2 3 4 5 ^_______

D4.5d

Probe:

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DOMAIN 5 Life Activities

• Household Activities

The following questions are about activities involved in maintaining your household, and in caring for the people with whom you live or those close to you. These activities include cooking, cleaning, shopping, caring for others and caring for your belongings.

D5.1 How many hours do you spend in these activities in a typical week?

RECORD NUMBER OF HOURS __/__

Because of your health condition, in the last 30 days, how much difficulty did you have in:

Extreme /Cannot Do

Number Days

D5.3 Doing your most important household

tasks well? 1 2 3 4 5 ^_______

D5.3d

D5.4 Getting all the household work done that

you needed to do? 1 2 3 4 5 ^_______

D5.4d

D5.5 Getting your household work done as

quickly as needed? 1 2 3 4 5 ^_______

D5.5d

None Mild Moderate Severe Extreme

/Cannot Do

D5.6 In the last 30 days, on how many days did you reduce or completely miss household work because of your health condition?

RECORD NUMBER OF DAYS __/__

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IF RESPONDENT WORKS (PAID, NON-PAID, SELF EMPLOYED) OR GOES TO SCHOOL, COMPLETE QUESTIONS D5.7-D5.13. OTHERWISE, SKIP TO D6.1 ON THE NEXT PAGE

Now I will ask some questions about your work or school activities.

D5.7 How many hours do you spend in

work (which includes school) in a typical week?

RECORD NUMBER OF HOURS __ /__

Because of your health condition, in the last 30 days how much difficulty did you have in:

Extreme /Cannot Do

Number Days

D5.9 Doing your most important work tasks

well? 1 2 3 4 5 ^_______

D5.9d

D5.10 Getting all the work done that you need

to do? 1 2 3 4 5 ^_______

D5.10d

D5.11 Getting your work done as quickly as

needed? 1 2 3 4 5 ^_______

D5.11d

D5.12 Have you had to work at a lower level because of a health condition?

No 1

Yes 2

D5.13 Did you earn less money as the result of a health condition?

No 1

Yes 2

None Mild Moderate Severe Extreme

/Cannot Do

P5.2 How much did these difficulties

interfere with your life? 1 2 3 4 5

D5.14 In the last 30 days, on how many days did you miss work for half a day or more because of your health condition?

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DOMAIN 6 Participation in Society

Now, I am going to ask you about your participation in society and the impact of your health problems on you and your family. Some of these questions may involve problems that go beyond the last 30 days, however in answering, please focus on the last 30 days. Again, I remind you to answer these questions while thinking about health problems: physical, mental or emotional, alcohol or drug related.

NOTE THAT THE NUMBER OF DAYS FOR EACH QUESTION IN THIS DOMAIN IS NOT REQUESTED.

In the last 30 days: ^None ^Mild ^Moderate ^Severe _{/Cannot Do}^Extreme D6.2 How much of a problem did you have

because of barriers or hindrances in the world around you?

1 2 ³ 4 5

D6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others?

1 2 ³ 4 5

D6.4 How much time did you spend on your

health condition, or its consequences? 1 2 3 4 5

D6.6 How much has your health been a drain on the financial resources of you or your family?

1 2 3 4 5

D6.7 How much of a problem did your family have because of your health problems?

1 2 3 4 5

D6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure?

1 2 3 4 5

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Probe: IF ANY OF D6.1 – D6.8 ARE RATED GREATER THAN NONE (1), ASK:

P6.1 How much did these problems interfere

P6.2 In the last 30 days, for how many days

did you have these difficulties? RECORD NUMBER OF DAYS __/__

H3 Overall, in the past 30 days, how many days did you experience any of the difficulties that we have discussed during this interview?

This concludes our interview, thank you for participating.

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Health Conditions:

• Diseases, illnesses or other health problems

• Injuries

• Mental or emotional problems

• Problems with alcohol

• Problems with drugs

Having difficulty with an activity means:

• Increased effort

• Discomfort or pain

• Slowness

• Changes in the way you do the activity

Think about the past 30 days only

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Flashcard #2

1 2 3 4 5

None Mild Moderate Severe Extreme

/ Cannot Do

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1

World Health Organization

For Office Use Only:

Disability Assessment Schedule II

__ __ __ - __ __ __ - ___

Center# Subject # - Time #

Phase 2 Field Trials – Health Services Research

12-Item Self-Administered Version __ __/ __ __ / __ __

Day / Month / Year

Pop: Dwelling:

q Gen 1 Independent

q Drg 1 Assisted

q Alc 1 Hospitalized

q Mnh q Phys q Other

H1 How do you rate your overall health in the past 30 days?

Very good Good Moderate Bad Very Bad

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 last 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.

S1 Standing for long periods such as 30 minutes?

S2 Taking care of your household responsibilities?

S3 Learning a new task, for example, learning how to get to a new place?

S5 How much have you been emotionally

affected by your health problems? ^None ^Mild ^Moderate ^Severe

Please continue to the next page …

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S6 Concentrating on doing something for

ten minutes? ^None ^Mild ^Moderate ^Severe

Extreme /Cannot

Do

kilometre [or equivalent]? ^None ^Mild ^Moderate ^Severe

Do

S8 Washing your whole body? None Mild Moderate Severe

Do

S9 Getting dressed? ^None ^Mild ^Moderate ^Severe ^Extreme^/Cannot

Do

S10 Dealing with people you do not know? None Mild Moderate Severe

Do

S11 Maintaining a friendship? ^None ^Mild ^Moderate ^Severe

Do

S12 Your day to day work? ^None ^Mild ^Moderate ^Severe

Do

H2 Overall, how much did these difficulties interfere with your life?

Not at all Mildly Moderately Severely Extremely

H4 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?

H5 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?

This completes the questionnaire. Thank you.

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WORLD HEALTH ORGANIZATION

DISABILITY ASSESSMENT SCHEDULE

WHODAS II

Phase 2 Field Trials – Health Services Research 12-Item Interviewer Administered Version

February 2000

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The WHO team:

CH – 1211 Geneva 27 Switzerland

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3

F4 INTERVIEW DATE ___ ___/___ ___/___ ___

month day year

Physical problems 5

Other (specify) 6

__________________________

(25)

PREAMBLE

A1 RECORD SEX AS OBSERVED Female 1

Male 2

Never married 1

Currently married 2

Separated 3

Divorced 4

Widowed 5

Cohabiting 6

(26)

5 A5 Which describes your main work status best?

Paid work 1

Student 4

Retired 6

Other (specify) 9

__________________________

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• Slowness

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7

SECTION 4. CORE QUESTIONS H1 How do you rate your overall

health in the past 30 days?

Read choices to respondent.

SHOW FLASHCARD #2 to participant

Extreme /Cannot Do

S1 Standing for long periods such as

30 minutes? 1 2 3 4 5

S2 Taking care of your household

responsibilities? 1 2 3 4 5

S3 Learning a new task, for example, learning how to get to a new

place? 1 2 3 4 5

1 2 3 4 5

S5 How much have you been emotionally affected by your

health problems? 1 2 3 4 5

Continue to next page…

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Extreme /Cannot Do

S6 Concentrating on doing something

for ten minutes? 1 2 3 4 5

kilometre [or equivalent]? 1 2 3 4 5

S8 Washing your whole body? 1 2 3 4 5

S9 Getting dressed? 1 2 3 4 5

S10 Dealing with people you do not

know? 1 2 3 4 5

S11 Maintaining a friendship? 1 2 3 4 5

S12 Your day to day work? 1 2 3 4 5

Read choices to respondent. 1 2 3 4 5

(30)

9

Health Conditions:

• Diseases, illnesses or other health problems

• Injuries

• Mental or emotional problems

• Problems with alcohol

• Problems with drugs

Having difficulty with an activity means:

• Increased effort

• Discomfort or pain

• Slowness

• Changes in the way you do the activity

Think about the past 30 days only

Flashcard #1

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Flashcard #2

1 2 3 4 5

None Mild Moderate Severe Extreme/

Cannot Do

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2

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World Health Organization

For Office Use Only:

Disability Assessment Schedule II

__ __ __ - __ __ __ - ___

Center# Subject # Time #

Phase 2 Field Trials – Health Services Research

36-Item Self-Administered Version __ __/ __ __ / __ __

Day / Month / Year

Pop: Dwelling:

q Gen 1 Independent

q Drg 1 Assisted

q Alc 1 Hospitalized

q Mnh q Phys q Other

H1 How do you rate your overall health in the past 30 days?

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 last 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.

Understanding and communicating

D1.1 Concentrating on doing something for ten minutes? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D1.2 Remembering to do important things? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D1.3 Analyzing and finding solutions to problems in day to

day life? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D1.4 Learning a new task, for example, learning how to get to

a new place? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D1.5 Generally understanding what people say? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D1.6 Starting and maintaining a conversation? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

Getting around

D2.1 Standing for long periods such as 30 minutes? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D2.2 Standing up from sitting down? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D2.3 Moving around inside your home? ^None ^Mild ^Moderate

Severe Extreme/

Cannot Do

D2.4 Getting out of your home? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D2.5 Walking a long distance such as a kilometre (or

equivalent)? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

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2 In the last 30 days, how much difficulty did you have in:

Self Care

D3.1 Washing your whole body? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D3.2 Getting dressed? ^None

Mild Moderate Severe Extreme/

Cannot Do

D3.3 Eating? ^None

Cannot Do

D3.4 Staying by yourself for a few days? ^None

Cannot Do

Getting along with people

D4.1 Dealing with people you do not know? ^None ^Mild

Moderate Severe Extreme/

Cannot Do

D4.2 Maintaining a friendship? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D4.3 Getting along with people who are close to you? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D4.4 Making new friends? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D4.5 Sexual activities? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

Life activities

D5.1 Taking care of your household responsibilities? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D5.2 Doing most important household tasks well? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D5.3 Getting all the household work done that you needed to do?

None Mild Moderate Severe Extreme/

Cannot Do

D5.4 Getting your household work done as quickly as needed?

Cannot Do

IF YOU WORK (PAID, NON-PAID, SELF EMPLOYED) OR GO TO SCHOOL, COMPLETE

QUESTIONS D5.5-D5.8 BELOW. OTHERWISE, SKIP TO D6.1 AT THE TOP OF THE NEXT PAGE.

D5.5 Your day to day work/school? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D5.6 Doing your most important work/school tasks well? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D5.7 Getting all the work done that you need to do? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

D5.8 Getting your work done as quickly as needed? ^None ^Mild ^Moderate ^Severe

Extreme/

Cannot Do

Please continue to the next page …

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In the last 30 days:

Participation in Society

D6.1 How much of a problem did you have in joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can

Cannot Do

D6.2 How much of a problem did you have because of barriers or hindrances in the world around you?

Cannot Do

D6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others

Cannot Do

D6.4 How much time did you spend on your health condition, or its consequences

Cannot Do

D6.5 How much have you been emotionally affected by your health condition

Cannot Do

D6.6 How much has your health been a drain on the financial resources of you or your family

Cannot Do

D6.7 How much of a problem did your family have because of your health problems

Cannot Do

D6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure

Cannot Do

Not at all Mildly Moderately Severely Extremely

This completes the questionnaire. Thank you.

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WORLD HEALTH ORGANIZATION

DISABILITY ASSESSMENT SCHEDULE

WHODAS II

Phase 2 Field Trials – Health Services Research 36-Item Interviewer Administered, Days Version

February 2000

(37)

The WHO team:

CH – 1211 Geneva 27 Switzerland

(38)

3

F4 INTERVIEW DATE ___ ___/___ ___/___ ___

month day year

Physical problems 5

Other (specify) 6

__________________________

(39)

PREAMBLE

A1 RECORD SEX AS OBSERVED Female 1

Male 2

Never married 1

Currently married 2

Separated 3

Divorced 4

Widowed 5

Cohabiting 6

(40)

5 A5 Which describes your main work status best?

Paid work 1

Student 4

Retired 6

Other (specify) 9

__________________________

(41)

• Slowness

(42)

7

SECTION 4. DOMAIN REVIEWS DOMAIN 1 Understanding and Communicating

I am going to ask some questions about understanding and communicating.

FOR RESPONSES GREATER THAN NONE (1), ASK: How many days was this difficulty present?

RECORD NUMBER OF DAYS (0 -30)

Do

Number Days

D1.1 Concentrating on doing something for ten

minutes? 1 2 3 4 5 ^________D1.1d

D1.2 Remembering to do important

things? 1 2 3 4 5 ^_______

D1.2d

D1.3 Analysing and finding solutions to

problems in day to day life? 1 2 3 4 5 ^_______

D1.3d

D1.4 Learning a new task, for example,

learning how to get to a new place? 1 2 3 4 5 _______

D1.4d

D1.5 Generally understanding what people

say? 1 2 3 4 5 ^_______

D1.5d

D1.6 Starting and maintaining a conversation? 1 2 3 4 5 ^_______

D1.6d

Probe:

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DOMAIN 2 Getting Around

I am now going to ask you about difficulties in getting around.

Do

Number Days

D2.1 Standing for long periods such as 30

minutes? 1 2 3 4 5 ^________D2.1d

D2.2 Standing up from sitting down? 1 2 3 4 5 ^_______

D2.2d

D2.3 Moving around inside your home? 1 2 3 4 5 ^_______

D2.3d

D2.4 Getting out of your home? 1 2 3 4 5 ^_______

D2.4d

D2.5 Walking a long distance such as a

kilometre [or equivalent]? 1 2 3 4 5 ^_______

D2.5d

Probe:

IF ANY OF D2.1 –D2.5 ARE RATED GREATER THAN NONE (1), ASK:

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9 DOMAIN 3 Self Care

I am now going to ask you about difficulties in taking care of yourself.

Do

Number Days

D3.1 Washing your whole body? 1 2 3 4 5 ^_______

D3.1d

D3.2 Getting dressed? 1 2 3 4 5 ^_______

D3.2d

D3.3 Eating? 1 2 3 4 5 ^_______

D3.3d

D3.4 Staying by yourself for a few days? 1 2 3 4 5 ^_______^D3.4d

Probe:

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DOMAIN 4 Getting along with people

I am now going to ask you about difficulties in getting along with people. Please remember that I am asking only about difficulties that are due to health problems. By this I mean diseases or illnesses, injuries, mental or emotional problems and problems with alcohol or drugs.

Do

Number Days

D4.1 Dealing with people you do not know? 1 2 3 4 5 ^_______

D4.1d

D4.2 Maintaining a friendship? 1 2 3 4 5 ^_______

D4.2d

D4.3 Getting along with people who are close

to you? 1 2 3 4 5 ^_______

D4.3d

D4.4 Making new friends? 1 2 3 4 5 ^_______

D4.4d

D4.5 Sexual activities? 1 2 3 4 5 ^_______

D4.5d

Probe:

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11 DOMAIN 5 Life Activities

• Household Activities

The following questions are about activities involved in maintaining your household, and in caring for the people with whom you live or those close to you. These activities include cooking, cleaning, shopping, caring for others and caring for your belongings.

D5.1 How many hours do you spend in these activities in a typical week?

RECORD NUMBER OF HOURS __/__

Because of your health condition, in the last 30 days, how much difficulty did you have in:

Do

Number Days

D5.2 Taking care of your household

responsibilities? 1 2 3 4 5 ^_______

D5.2d

D5.3 Doing your most important household

tasks well? 1 2 3 4 5 ^_______

D5.3d

D5.4 Getting all the household work done that

you needed to do? 1 2 3 4 5 ^_______

D5.4d

D5.5 Getting your household work done as

quickly as needed? 1 2 3 4 5 ^_______

D5.5d

D5.6 In the last 30 days, on how many days did you reduce or completely miss household work because of your health condition?

RECORD NUMBER OF DAYS __/__