Disability Assessment QuestionnaireDisability Assessment QuestionnaireMichael Frampton M.D., P.C.9120 Connecticut Drive, Suite AMerrillville, IN 46410First NameMiddle InitialLast NameSuffix (Sr, Jr, etc.)Sex:Sex: Male FemaleToday's DateThis 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 click on only one response. This is a multi-part form, so please complete each section before clicking the "Next" button to move to the next part of the form.In the Last 30 Days, How Much Trouble Did You Have in Understanding and Communicating:D1.1 - Concentrating on doing something for ten minutes? D1.1 - Concentrating on doing something for ten minutes? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD1.2 - Remembering to do important things?D1.2 - Remembering to do important things? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD1.3 - Analyzing and finding solutions to problems in day-to-day life?D1.3 - Analyzing and finding solutions to problems in day-to-day life? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD1.4 - Learning a new task, for example, learning how to get to a new place?D1.4 - Learning a new task, for example, learning how to get to a new place? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD1.5 -Generally understanding what people say?D1.5 -Generally understanding what people say? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD1.6 -Starting and maintaining a conversation?D1.6 -Starting and maintaining a conversation? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD1 Section Total:PreviousNextDisability Assessment Questionnaire - Part 2Michael Frampton M.D., P.C.9120 Connecticut Drive, Suite AMerrillville, IN 46410In the Last 30 Days, How Much Trouble Did You have in Getting Around:D2.1 - Standing for long periods, such as 30 minutes?D2.1 - Standing for long periods, such as 30 minutes? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD2.2 - Standing up from sitting down?D2.2 - Standing up from sitting down? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD2.3 - Moving around inside your home?D2.3 - Moving around inside your home? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD2.4 - Getting out of your home?D2.4 - Getting out of your home? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD2.5 - Walking a long distance, such as a kilometer (or equivalent)?D2.5 - Walking a long distance, such as a kilometer (or equivalent)? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD2 Section Total:PreviousNextDisability Assessment Questionnaire - Part 3Michael Frampton M.D., P.C.9120 Connecticut Drive, Suite AMerrillville, IN 46410In the Last 30 Days, How Much Trouble did You Have in Self-Care:D3.1 - Washing your whole body?D3.1 - Washing your whole body? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD3.2 - Getting Dressed?D3.2 - Getting Dressed? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD3.3 - Eating?D3.3 - Eating? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD3.4 - Staying by yourself for a few days?D3.4 - Staying by yourself for a few days? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD3 Section TotalPreviousNextDisability Assessment Questionnaire - Part 4Michael Frampton M.D., P.C.9120 Connecticut Drive, Suite AMerrillville, IN 46410In the Last 30 Days, How Much Trouble Did You Have Getting Along with People:D4.1 - Dealing with people you do not know?D4.1 - Dealing with people you do not know? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD4.2 - Maintaining a friendship?D4.2 - Maintaining a friendship? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD4.3 - Getting along with people who are close to you?D4.3 - Getting along with people who are close to you? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD4.4 - Making new friends?D4.4 - Making new friends? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD4.5 - Sexual Activities?D4.5 - Sexual Activities? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD4 Section Total:PreviousNextDisability Assessment Questionnaire - Part 5Michael Frampton M.D., P.C.9120 Connecticut Drive, Suite AMerrillville, IN 46410In the Last 30 Days, How Much Trouble did You Have in Life Activities - Household:D5.1 - Taking care of your household responsibilities?D5.1 - Taking care of your household responsibilities? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD5.2 - Doing most important household tasks well?D5.2 - Doing most important household tasks well? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD5.3 - Getting all of the household work done that you needed to do?D5.3 - Getting all of the household work done that you needed to do? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD5.4 - Getting your household work done as quickly as needed?D5.4 - Getting your household work done as quickly as needed? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD5 Section Total:PreviousNextDisability Assessment Questionnaire - Part 5BMichael Frampton M.D., P.C.9120 Connecticut Drive, Suite AMerrillville, IN 46410If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5–D5.8, below. Otherwise, skip to D6.1.In the Last 30 Days, How Much Trouble did You Have in Life Activities - School/Work:D5.5 - Your day-to-day work/school?D5.5 - Your day-to-day work/school? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD5.6 - Doing your most important work/school tasks well?D5.6 - Doing your most important work/school tasks well? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD5.7 - Getting all of the work done that you need to do?D5.7 - Getting all of the work done that you need to do? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD5.8 - Getting your work done as quickly as needed?D5.8 - Getting your work done as quickly as needed? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD5 Part 2 Section Total:PreviousNextDisability Assessment Questionnaire - Part 6Michael Frampton M.D., P.C.9120 Connecticut Drive, Suite AMerrillville, IN 46410In the Last 30 Days, How Much Trouble did You Have in 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?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? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD6.2 - How much of a problem did you have because of barriers or hindrances around you?D6.2 - How much of a problem did you have because of barriers or hindrances around you? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD6.3 - How much of a problem did you have living with dignity because of the attitudes and actions of others?D6.3 - How much of a problem did you have living with dignity because of the attitudes and actions of others? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD6.4 - How much time did you spend on your health condition or its consequences?D6.4 - How much time did you spend on your health condition or its consequences? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD6.5 - How much have you been emotionally affected by your health condition?D6.5 - How much have you been emotionally affected by your health condition? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD6.6 - How much has your health been a drain on the financial resources of you or your family?D6.6 - How much has your health been a drain on the financial resources of you or your family? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD6.7 - How much of a problem did your family have because of your health problems?D6.7 - How much of a problem did your family have because of your health problems? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD6.8 - How much of a problem did you have in doing things by yourself for relaxation or pleasure?D6.8 - How much of a problem did you have in doing things by yourself for relaxation or pleasure? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme or Cannot DoD6 Section TotalDisability Assessment Total:Measure: WHODAS 2.0 (World Health Organization Disability Assessment Schedule 2.0): 36-item version, self-administered © World Health Organization, 2012. Measuring health and disability: manual for WHO Disability Assessment Schedule (WHODAS 2.0), World Health Organization, 2010, Geneva. Rights granted: The World Health Organization has granted the Publisher permission for the reproduction of this instrument. This material can be reproduced without permission by clinicians for use with their own patients. Any other use, including electronic use, requires written permission from WHO. Rights holder: World Health Organization (WHO) To request permission for any other use beyond what is stipulated above, contact: World Health Organization (WHO)Email Address:Retype Email Address:PreviousSubmit Form
