We would like to know how you are doing with activities or feelings that can sometimes be affected by stroke.
Each question will ask about a specific activity or feeling.
For each question, think about how you have been in the past week.
The first set of questions ask about how much trouble you have had with daily activities
For example:
DURING THE PAST WEEK
How much trouble did you have:
Tying your shoelaces?
Point to the box that best describes how much trouble you have had with each activity in the past week
The next set of questions ask about how much trouble you have had communicating with other people
17. Speaking?
18. Speaking clearly enough to use the telephone?
19. Getting other people to understand you?
20. Finding the word you wanted to say?
21. Getting other people to understand you even when you repeated yourself?
The last set of questions ask about your family and social life
Did you:
34. Feel that your language problems interfered with your family life?
39. Feel that your language problems interfered with your social life?
To maintain anonymity enter name by hand once you have printed the form:
Respondent name:______________________________________________