Screening Tool for disability index

The STANFORD HEALTH ASSESSMENT QUESTIONNAIRE
Stanford University School of Medicine, Division of Immunology & Rheumatology
HAQ Disability Index:
In this section we are interested in learning how your illness affects your ability to function in daily
life. Please feel free to add any comments on the back of this page.
Please check the response which best describes your usual abilities OVER THE PAST WEEK:
Without ANY
difficulty
0
With SOME
difficulty
1
With MUCH
difficulty 2
UNABLE
to do 3
DRESSING & GROOMING
Are you able to:
-Dress yourself, including tying
shoelaces and doing buttons?
-Shampoo your hair?
ARISING
Are you able to:
-Stand up from a straight chair?
-Get in and out of bed?
EATING
Are you able to:
-Cut your meat?
-Lift a full cup or glass to your mouth?
-Open a new milk carton?
WALKING
Are you able to:
-Walk outdoors on flat ground?
-Climb up five steps?
Please check any AIDS OR DEVICES that you usually use for any of these activities:
Cane
Walker
Crutches
Wheelchair
Devices used for dressing (button hook, zipper pul
long-handled shoe horn, etc.)
Built up or special utensils
Special or built up chair
Other (Specify: )
Please check any categories for which you usually need HELP FROM ANOTHER PERSON:
Dressing and Grooming
Arising
Eating
Walking
Please check the response which best describes your usual abilities OVER THE PAST WEEK:
Without ANY
difficulty 0
With SOME
difficulty 1
With MUCH
difficulty 2
UNABLE
to do 3
HYGIENE
Are you able to:
-Wash and dry your body?
-Take a tub bath?
-Get on and off the toilet?
REACH
Are you able to:
-Reach and get down a 5-pound
object (such as a bag of sugar) from
just above your head?
-Bend down to pick up clothing
from the floor?
GRIP
Are you able to:
-Open car doors?
-Open jars which have been
previously opened?
-Turn faucets on and off?
ACTIVITIES
Are you able to:
-Run errands and shop?
-Get in and out of a car?
-Do chores such as vacuuming or
yardwork
Please check any AIDS OR DEVICES that you usually use for any of these activities:
Raised toilet seat
Bathtub seat
Jar opener (for jars previously
opened)
Bathtub bar
Long-handled appliances for reach
Long-handled appliances in bathroom
Other (Specify: )
Please check any categories for which you usually need HELP FROM ANOTHER PERSON:
Hygiene
Reach
Gripping and opening things
Errands and chores
We are also interested in learning whether or not you are affected by pain because of your illness.
How much pain have you had because of your illness IN THE PAST WEEK:
PLACE A VERTICAL () MARK ON THE LINE TO INDICATE THE SEVERITY OF THE PAIN
No Pain Severe Pain

0 100
Considering all the ways that your arthritis affects you, rate how you are doing on the following scale by
placing a vertical mark on the line.
Very Well Very Poor

0 100