Mobility I have no problems in walking aboutI have slight problems in walking aboutI have moderate problems in walking aboutI have severe problems in walking aboutI am unable to walk about
Self-Care I have no problems washing or dressing myselfI have slight problems washing or dressing myselfI have moderate problems washing or dressing myselfI have severe problems washing or dressing myselfI am unable to wash or dress myself
Usual Activities I have no problems doing my usual activitiesI have slight problems doing my usual activitiesI have moderate problems doing my usual activitiesI have severe problems doing my usual activitiesI am unable to do my usual activities
Pain / Discomfort I have no pain or discomfortI have slight pain or discomfortI have moderate pain or discomfortI have severe pain or discomfortI have extreme pain or discomfort
Anxiety / Depression I am not anxious or depressedI am slightly anxious or depressedI am moderately anxious or depressedI am severely anxious or depressedI am extremely anxious or depressed
We would like to know how good or bad your health is TODAY.
On a scale from 0 to 100 where 100 means the best health you can imagine and 0 is the worst health you can imagine, where do you feel like your health is?
Please click to confirm you accept the Privacy Policy
Name
Email
Hospital Physio Email
Pain
1. Walking
01234
2. Stair climbing
3. Nocturnal
4. Rest
5. Weight bearing
Stiffness
1. Morning stiffness
2. Stiffness occurring later in the day
Physical Function
1. Descending stairs
2. Ascending stairs
3. Rising from sitting
4. Standing
5. Bending to floor
6. Walking on flat surface
7. Getting in / out of car
8. Going Shopping
9. Putting on socks
10. Lying in bed
11. Taking off socks
12. Rising from bed
13. Getting in/out of bath
14. Sitting
15. Getting on/off toilet
16. Heavy domestic duties
17. Light domestic duties
