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This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.

Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities.

For each question, please select only one response

In the past 30 days, how much difficulty did you have in...

Standing for long periods such as 30 minutes?

None Mild Moderate Severe Extreme or cannot do

Taking care of your household responsibilities?

None Mild Moderate Severe Extreme or cannot do

Learning a new task, for example, learning how to get to a new place?

None Mild Moderate Severe Extreme or cannot do

How much of a problem did you have in joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?

None Mild Moderate Severe Extreme or cannot do

How much have you been emotionally affected by your health problems?

None Mild Moderate Severe Extreme or cannot do

Concentrating on doing something for ten minutes?

None Mild Moderate Severe Extreme or cannot do

Walking a long distance such as a kilometre (or equivalent)?

None Mild Moderate Severe Extreme or cannot do

Washing your whole body?

None Mild Moderate Severe Extreme or cannot do

Getting dressed?

None Mild Moderate Severe Extreme or cannot do

Dealing with people you do not know?

None Mild Moderate Severe Extreme or cannot do

Maintaining a friendship?

None Mild Moderate Severe Extreme or cannot do

Your day-to-day work?

None Mild Moderate Severe Extreme or cannot do

Overall, in the past 30 days, how many days were these difficulties present? (type number of days)

In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition? (type number of days)

In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition? (type number of days)

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