Disability Index (GPDI)

Name*

First NameLast Name

Age*

Gender*

Date*

Date

The rating scales below are designed to measure the degree to which several aspects of your life are presently disrupted by your health condition. In other words, For each category, please rate how your health condition is preventing you from doing what you would normally do, or from doing it as well as you normally would.

For each of the 5 categories of life activity listed, please choose a number between 0 and 10 to indicate how disabled you are due to your health condition.

A score of 0 means no disability at all, and a score of 10 signifies total disability.

(1) Family / Home responsibilities This category refers to activities related to the home or family. It includes chores or duties performed around the house (e.g. yard work) and errands or favors for other family members (e.g. driving the children to school).*

(2) Recreation This category includes hobbies, sports, and other leisure time activities.*

(3) Social Activity This category refers to activities that involve participation with friends and acquaintances other than family members. It includes parties, theatre, concerts, dining out, and other social functions.*

(4) Occupation This category refers to activities that are part of or directly related to one's job. This includes non-paying jobs such as that of a housewife or volunteer work.*

(5) Self-care This category includes activities which involve personal maintenance and independent daily living (e.g. taking a shower, getting dressed, etc.)*

Form

Disability Index (GPDI)