This questionnaire asks about difficulties due to health conditions. A health condition includes diseases, illnesses, injuries, mental or emotional problems, and problems with alcohol or drugs. Think about the last30 days and respond based on how much difficulty you have had in the following areas.
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Date
-
Month
-
Day
Year
Date
None (0) = No difficulty Mild (1) = Little difficulty Moderate (2) = Moderate difficulty Severe (3) = A lot of difficulty Extreme/Cannot Do (4) = Cannot do at all
Concentrating on doing something for tenminutes?
1
2
3
4
Remembering to do important things?
1
2
3
4
Analyzing and finding solutions to problems inday-to-day life?
1
2
3
4
Learning a new task, such as learning how to get to a new place?
1
2
3
4
Generally understanding what people say?
1
2
3
4
Starting and maintaining a conversation?
1
2
3
4
Standing for long periods, such as 30 minutes?
1
2
3
4
Standing up from sitting down?
1
2
3
4
Walking a short distance, such as 100 meters?
1
2
3
4
Washing your whole body?
1
2
3
4
Getting Dressed?
1
2
3
4
Eating
1
2
3
4
Getting Along with people?
1
2
3
4
Making new friends?
1
2
3
4
Walking a long distance?
1
2
3
4
Dealing with people that you know?
1
2
3
4
Sexual Activities?
1
2
3
4
Taking care of household responsibilities?
1
2
3
4
Your day to day work/school?
1
2
3
4
How much of a problem did you have joining in community activities (festivities,religious or other
1
2
3
4
How much of a problem did you have living with dignity due to your health condition?
1
2
3
4
How much of a problem did you have doing things by yourself for relaxation or pleasure?
1
2
3
4
How much has your health been a drain on your financial resources?
1
2
3
4
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Next
DASS- Depression Anxiety Stress Scale
Instructions: Please read each statement and indicate how much it appliedto you over the past week.0 = Did not apply to me at all1 = Applied to me some degree, or some of the time2 = Applied to me a considerable degree, or a good part ofthe time3 = Applied to me very much, or most of the time
Name
First Name
Last Name
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Date
-
Month
-
Day
Year
Date
0 = Did not apply to me at all1 = Applied to me some degree, or some of the time2 = Applied to me a considerable degree, or a good part ofthe time3 = Applied to me very much, or most of the time
I was unable to experience any positive feelings.
1
2
3
I felt down-hearted and blue.
1
2
3
I felt down-hearted and blue.
1
2
3
I felt down-hearted and blue.
1
2
3
I felt down-hearted and blue.
1
2
3
I felt down-hearted and blue.
1
2
3
I found it difficult to work up the initiativeto do things.
1
2
3
I felt that life was meaningless.
1
2
3
I had difficulty experiencing enjoyment from activities.
1
2
3
I felt I had nothing to look forward to.
1
2
3
I felt I was close to panic.
1
2
3
I felt scared without any good reason.
1
2
3
I had difficulty relaxing.
1
2
3
I experienced trembling (e.g., hands shaking).
1
2
3
I felt like I was going to panic or make a fool of myself.
1
2
3
I found it difficult to tolerate interruptions or delays.
1
2
3
I felt irritable and easily upset.
1
2
3
I found it hard to calm down after something upset me.
1
2
3
I tended to overreact to situations.
1
2
3
Submit
Should be Empty: