Multi-Dimensional Health Assessment Questionnaire

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This questionnaire includes information not available from blood tests, X-rays, or any source other than you. Please try to answer each question, even if you do not think it is related to you at this time. Try to complete as much as you can yourself, but if you need help, please ask. There are no right or wrong answers. Please answer exactly as you think or feel.
Thank you.

Multi-Dimensional Health Assessment Questionnaire
  • Daily Task Difficulty
  • Pain Level
  • Affected Joint
  • Wellness
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1. Please choose the ONE best answer for your abilities at this time. OVER THE LAST WEEK, were you able to:

a. Dress yourself, including tying shoelaces and doing buttons? *
b. Get in and out of bed? *
c. Lift a full cup or glass to your mouth? *
d. Walk outdoors on flat ground? *
e. Wash and dry your entire body? *
f. Bend down to pick up clothing from the floor? *
g. Turn regular faucets on and off? *
h. Get in and out of a car, bus, train, or airplane? *
i. Walk two miles or three kilometers, if you wish? *
j. Participate in recreational activities and sports as you like, if you wish? *
k. Get a good night's sleep? *
l. Deal with feelings of anxiety or being nervous? *
m. Deal with feelings of anxiety or being nervous? *
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