Patient Forms Disability Assessment: World Health Organization Disability Assessment Schedule 2.0 Name* Today's Date* Age* GenderMaleFemaleThis questionnaire asks about difficulties due to health/mental 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 chose one response.In the last 30 days, how much difficulty did you have in:UNDERSTANDING & COMMUNICATING 1.1 Concentrating on doing something for ten minutes?NoneMildModerateSevereExtreme or cannot do 1.2 Remembering to do important things?NoneMildModerateSevereExtreme or cannot do 1.3 Analyzing and finding solutions to problems in day-to-day life?NoneMildModerateSevereExtreme or cannot do 1.4 Learning a new task, for example, learning how to get to a new place?NoneMildModerateSevereExtreme or cannot do 1.5 Generally understanding what people say?NoneMildModerateSevereExtreme or cannot do 1.6 Starting and maintaining a conversation?NoneMildModerateSevereExtreme or cannot doGETTING AROUND 2.1 Standing for long periods, such as 30 minutes?NoneMildModerateSevereExtreme or cannot do 2.2 Standing up from sitting down?NoneMildModerateSevereExtreme or cannot do 2.3 Moving around inside your home?NoneMildModerateSevereExtreme or cannot do 2.4 Getting out of your home?NoneMildModerateSevereExtreme or cannot do 2.5 Walking a long distance, such as a kilometer (or equivalent)?NoneMildModerateSevereExtreme or cannot doSELF CARE 3.1 Washing your whole body?NoneMildModerateSevereExtreme or cannot do 3.2 Getting dressed?NoneMildModerateSevereExtreme or cannot do 3.3 Eating?NoneMildModerateSevereExtreme or cannot do 3.4 Staying by yourself for a few days?NoneMildModerateSevereExtreme or cannot doGETTING ALONG WITH PEOPLE 4.1 Dealing with people you do not know?NoneMildModerateSevereExtreme or cannot do 4.2 Maintaining a friendship?NoneMildModerateSevereExtreme or cannot do 4.3 Getting along with people who are close to you?NoneMildModerateSevereExtreme or cannot do 4.4 Making new friends?NoneMildModerateSevereExtreme or cannot do 4.5 Sexual activities?NoneMildModerateSevereExtreme or cannot doLIFE ACTIVITIES: HOUSEHOLD 5.1 Taking care of your household responsibilities?NoneMildModerateSevereExtreme or cannot do 5.2 Doing most important household tasks well?NoneMildModerateSevereExtreme or cannot do 5.3 Getting all of the household work done that you needed to do?NoneMildModerateSevereExtreme or cannot do 5.4 Getting your household work done as quickly as needed?NoneMildModerateSevereExtreme or cannot doLIFE ACTIVITIES: SCHOOL / WORKIf you work (paid, non-paid, self-employed) or go to school, complete questions 5.5–5.8, below. Otherwise, skip to 6.1.Because of your health condition, in the past 30 days, how much difficulty did you have in: 5.5 Your day-to-day work/school?NoneMildModerateSevereExtreme or cannot do 5.6 Doing your most important work/school tasks well?NoneMildModerateSevereExtreme or cannot do 5.7 Getting all of the work done that you need to do?NoneMildModerateSevereExtreme or cannot do 5.8 Getting your work done as quickly as needed?NoneMildModerateSevereExtreme or cannot doPARTICIPATION IN SOCIETYIn the past 30 days: 6.1 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?NoneMildModerateSevereExtreme or cannot do 6.2 How much of a problem did you have because of barriers or hindrances around you?NoneMildModerateSevereExtreme or cannot do 6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others?NoneMildModerateSevereExtreme or cannot do 6.4 How much time did you spend on your health condition or its consequences?NoneMildModerateSevereExtreme or cannot do 6.5 How much have you been emotionally affected by your health condition?NoneMildModerateSevereExtreme or cannot do 6.6 How much has your health been a drain on the financial resources of you or your family?NoneMildModerateSevereExtreme or cannot do 6.7 How much of a problem did your family have because of your health problems?NoneMildModerateSevereExtreme or cannot do 6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure?NoneMildModerateSevereExtreme or cannot do reCAPTCHASubmitReset
