Kenneth Stark, MD, PA, Dr. Nina Blum
OVER THE LAST WEEK WERE YOU ABLE TO DO THE FUNCTIONS LISTED BELOW? (please make your choice from the list ABOVE each question)
1. Dress yourself, including tying shoelaces and doing buttons?
2. Get in and out of bed?
3.Lift a cup or glass to your mouth?
4. Walk outdoors on flat ground
5. Wash and dry your entire body?
6. Bend down to pick up clothing from the floor?
7. Turn regular faucet on and off?
8. Get in and out of a car, bus, train, or plane?
9. Walk two miles or 3 kilometers, if you wish?
10. Participate in recreational activities and sports as you like, if you wish?
How much PAIN have you had because of your illness in the PAST WEEK? Please select from below between 0-10 to indicate how severe your pain has been:
Considering all the ways in which illness and health conditions may affect you at this time, please select from below between 0-10 to show how you are doing:
