The Health Assessment Questionnaire

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Please tell us how your arthritis affects your ability to carry out your daily activities OVER THE PAST WEEK:

	Without ANY Difficulty	With SOME Difficulty	With MUCH Difficulty	UNABLE To Do
Dress yourself	Without ANY Difficulty	With SOME Difficulty	With MUCH Difficulty	UNABLE To Do
Shampoos your hair	Without ANY Difficulty	With SOME Difficulty	With MUCH Difficulty	UNABLE To Do
Get in and out of bed	Without ANY Difficulty	With SOME Difficulty	With MUCH Difficulty	UNABLE To Do
Stand up from a chair	Without ANY Difficulty	With SOME Difficulty	With MUCH Difficulty	UNABLE To Do
Lift a full cup of milk	Without ANY Difficulty	With SOME Difficulty	With MUCH Difficulty	UNABLE To Do
Cut your meat	Without ANY Difficulty	With SOME Difficulty	With MUCH Difficulty	UNABLE To Do
Walk outdoors	Without ANY Difficulty	With SOME Difficulty	With MUCH Difficulty	UNABLE To Do
Climb 5 Steps	Without ANY Difficulty	With SOME Difficulty	With MUCH Difficulty	UNABLE To Do

Please check any AIDS OR DEVICES that you usually use for any of the activities in the above Question:

Cane

Walker

Crutches

Wheelchair

Device for Dressing

Special Utensils

Special Chair

Please check any categories for which you usually need HELP FROM ANOTHER PERSON:

Dressing

Grooming

Arising

Eating

Walking