Shopping Cart
Your Cart is Empty
There was an error with PayPalClick here to try again
CelebrateThank you for your business!You should be receiving an order confirmation from Paypal shortly.Exit Shopping Cart


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 circle only one response.

Answer questions based upon THE PAST 30 (THIRTY) Days

D1.1 Concentrating on doing something for ten minutes?*
D1.2 Remembering to do important things?*
D1.3 Analysing and finding solutions to problems in day-to-day life?*
D1.4 Learning a new task, for example, learning how to get to a new place?*
D1.5 Generally understanding what people say?*
D1.6 Starting and maintaining a conversation? *
D2.1 Standing for long periods such as 30 minutes?*
D2.2 Standing up from sitting down?*
D2.3 Moving around inside your home?*
D2.4 Getting out of your home?*
D2.5 Walking a long distance such as a kilometre [or equivalent]?*
D3.1 Washing your whole body?*
D3.2 Getting dressed?*
D3.3 Eating?*
D3.4 Staying by yourself for a few days?*
D4.1 Dealing with people you do not know?*
D4.2 Maintaining a friendship?*
D4.3 Getting along with people who are close to you?*
D4.4 Making new friends?*
D4.5 Sexual activities?*
D5.1 Taking care of your household responsibilities?*
D5.2 Doing most important household tasks well?*
D5.3 Getting all the household work done that you needed to do?*
D5.4 Getting your household work done as quickly as needed?*
D5.5 Your day-to-day work/school?*
D5.6 Doing your most important work/school tasks well?*
D5.7 Getting all the work done that you need to do?*
D5.8 Getting your work done as quickly as needed?*
D6.1 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? *
D6.2 How much of a problem did you have because of barriers or hindrances in the world around you?*
D6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others?*
D6.4 How much time did you spend on your health condition, or its consequences?*
D6.5 How much have you been emotionally affected by your health condition?*
D6.6 How much has your health been a drain on the financial resources of you or your family?*
D6.7 How much of a problem did your family have because of your health problems?*
D6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure?*
This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.

Thank you! Your message was sent successfully.

Return to Forms