Disability Assessment Questionnaire

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

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:

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:

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:

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:

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:

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:

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:
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)