FUNCAP27 questionnaire

FUNCAP27 questionnaire

This questionnaire evaluates your functional capacity for a range of activities. No days are the same. Base your response on an average day during the last month – not the worst nor the best. If a question concerns an activity that you have not performed, such as showering while seated because you always shower standing up, then score as you think this activity would have affected you.
1. Using the toilet (not bedpan or bedside commode)

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
2. Showering standing up

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
3. Getting dressed in regular clothes

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
4. Walking a short distance indoors, from one room to another

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
5. Walking between approx. 100 m and 1 km on level ground (length of 1 to 10 football fields)

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
6. Physical activity with increased heart rate, for approx. 15 min

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
7. Sitting in bed for approx. 30 min

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
8. Sitting in an upright chair (dining chair) with feet on floor for approx. 2 hours

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
9. Standing up for approx. 5 minutes, e.g. while queuing or while cooking

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
10. Heavier housework (washing floors, vacuuming etc.) for approx. 1/2 hour continuously

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
11. Cooking a complicated meal from scratch, approx. 1 hour of preparation

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
12. Having a conversation for approx. 5 minutes

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
13. Participating in a conversation with three people for approx. 1/2 hour

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
14. Participating in a dinner party, party or family event

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
15. Stepping right outside your home

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
16. Going to a shop for groceries

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
17. Using public transport (bus or train)

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
18. Participating in organized leisure activities such as classes, sports etc.

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
19. Staying in a room with normal lighting, without sunglasses, for approx.1 hour

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
20. Staying outdoors in daylight without sunglasses for approx. 2 hours

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
21. Staying in a noisy environment, (shopping mall, café or open plan office) for approx. 1 hour

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
22. Reading a short text, such as a mobile phone text message

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
23. Reading and understanding a non-fiction text, such as an official document one A4 page long

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
24. Using social media to stay in touch with others

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
25. Focusing on a task for approx. 10 minutes continuously

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
26. Focusing on a task for approx. 2 hours continuously

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
27. Managing a full working day (non-physical work such as office work,classes or lectures)

0: I cannot do this1: My capacity will be severely reduced for at least three days2: I can do little else on the same day and for one to two days afterwards3: I can do little else on the same day4: I must limit other activities on the same day5: This rarely affects other activities6: Unproblematic – does not affect other activities
Total
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