Disability Assessment Questionnaire

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

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Last Name

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Today's Date

This 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?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D1.2 - Remembering to do important things?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

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 Do

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 Do

D1.5 -Generally understanding what people say?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D1.6 -Starting and maintaining a conversation?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D1 Section Total:

Disability Assessment Questionnaire - Part 2

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

In the Last 30 Days, How Much Trouble Did You have in Getting Around:

D2.1 - Standing for long periods, such as 30 minutes?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D2.2 - Standing up from sitting down?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D2.3 - Moving around inside your home?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D2.4 - Getting out of your home?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D2.5 - Walking a long distance, such as a kilometer (or equivalent)?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D2 Section Total:

Disability Assessment Questionnaire - Part 3

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

In the Last 30 Days, How Much Trouble did You Have in Self-Care:

D3.1 - Washing your whole body?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D3.2 - Getting Dressed?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D3.3 - Eating?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D3.4 - Staying by yourself for a few days?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D3 Section Total

Disability Assessment Questionnaire - Part 4

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

In the Last 30 Days, How Much Trouble Did You Have Getting Along with People:

D4.1 - Dealing with people you do not know?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D4.2 - Maintaining a friendship?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D4.3 - Getting along with people who are close to you?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D4.4 - Making new friends?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D4.5 - Sexual Activities?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D4 Section Total:

Disability Assessment Questionnaire - Part 5

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

In the Last 30 Days, How Much Trouble did You Have in Life Activities - Household:

D5.1 - Taking care of your household responsibilities?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D5.2 - Doing most important household tasks well?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot 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 Do

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

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D5 Section Total:

Disability Assessment Questionnaire - Part 5B

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

If 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?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D5.6 - Doing your most important work/school tasks well?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot 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 Do

D5.8 - Getting your work done as quickly as needed?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

D5 Part 2 Section Total:

Disability Assessment Questionnaire - Part 6

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

In 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?

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extreme or Cannot Do

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 Do

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 Do

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 Do

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 Do

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 Do

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 Do

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 Do

D6 Section Total

Disability 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)

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