WHODAS2
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.
Name *
1st name and initial only please, no surname. Eg: Chris S
Your answer
Understanding and communicating
In the last 30 days, how much difficulty did you have in:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme or cannot to
D1.1 Concentrating on doing something for ten minutes?
D1.2 Remembering to do important things?
D1.3 Analyzing and finding solutions to problems in day-to-day life?
D1.4 Learning a new task, for example, learning how to get to a new place?
D1.5 Generally understanding what people say?
D1.6 Starting and maintaining a conversation?
Getting around
In the last 30 days, how much difficulty did you have in:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme or cannot to
D2.1 Standing for long periods, such as 30 minutes?
D2.2 Standing up from sitting down?
D2.3 Moving around inside your home?
D2.4 Getting out of your home?
D2.5 Walking a long distance, such as a kilometer (or equivalent)?
Self-care
In the last 30 days, how much difficulty did you have in:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme or cannot to
D3.1 Washing your whole body?
D3.2 Getting dressed?
D3.3 Eating?
D3.4 Staying by yourself for a few days?
Getting along with people
In the last 30 days, how much difficulty did you have in:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme or cannot to
D4.1 Dealing with people you do not know?
D4.2 Maintaining a friendship?
D4.3 Getting along with people who are close to you?
D4.4 Making new friends?
D4.5 Sexual activities?
Life activities—Household
In the last 30 days, how much difficulty did you have in:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme or cannot to
D5.1 Taking care of your household responsibilities?
D5.2 Doing most important household tasks well?
D5.3 Getting all of the household work done that you needed to do?
D5.4 Getting your household work done as quickly as needed?
Life activities—School/Work
If you work (paid, non-paid, self-employed) or go to school, complete questions below. Otherwise, skip to Participation in Society``. Because of your health condition, in the past 30 days, how much difficulty did you have in:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme or cannot to
D5.5 Your day-to-day work/school?
D5.6 Doing your most important work/school tasks well?
D5.7 Getting all of the work done that you need to do?
D5.8 Getting your work done as quickly as needed?
Participation in society
In the past 30 days:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme or cannot to
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?
D6.2 How much of a problem did you have because of barriers or hindrances around you?
D6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others?
D6.4 How much time did you spend on your health condition or its consequences?
D6.5 How much have you been emotionally affected by your health condition?
D6.6 How much has your health been a drain on the financial resources of you or your family?
D6.7 How much of a problem did your family have because of your health problems?
D6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service