Mobility | |
I have no problems in walking about | □ |
I have some problems in walking about | □ |
I am confined to bed | □ |
Self-care | |
I have no problems with self-care | □ |
I have some problems washing or dressing myself | □ |
I am unable to wash or dress myself | □ |
Usual activities (e.g. work, study, housework, family or leisure activities) | |
I have no problems with performing my usual activities | □ |
I have some problems with performing my usual activities | □ |
I am unable to perform my usual activities | □ |
Pain/discomfort | |
I have no pain or discomfort | □ |
I have moderate pain or discomfort | □ |
I have extreme pain or discomfort | □ |
Anxiety/depression | |
I am not anxious or depressed | □ |
I am moderately anxious or depressed | □ |
I am extremely anxious or depressed | □ |