This free survey is powered by
  1. Surveys
  2. 2014
  3. July
  4. M
  5. Musculoskeletal Function Assessment
0%
Exit Survey
 
 
INSTRUCTIONS
We are interested in finding out how you are managing with your injury or arthritis this week. Please answer "YES" or "NO" to each question. If the question is true for you and is related to your injury or arthritis, choose "YES". If the question is not true for you and is not related to your injury or arthritis, choose "NO". If you wish to comment on any of the questions, please use the comment box below each subset of questions. Please answer all questions, even though some of the questions may not apply to your injury or arthritis.
 
 
 
PLEASE WRITE IN TODAY'S DATE:
   
 
 
ACTIVITIES USING YOUR ARMS OR LEGS
This first set of questions is about changes or problems you may have using your arms or legs to do such things as reaching, walking, and carrying.
This week, because of your injury or arthritis...
YES NO
1. Are you able to walk?
2. Do you feel unsteady on your feet?
3. Is it difficult for you to reach up high?
4. Do you straighten or bend your arm(s) completely?
5. Do you straighten or bend your leg(s) completely?
6. Do you pivot?
7. Do you climb up and down ladders?
8. Do you have to rest often when walking?
9. Do you avoid stairs?
10. Do you stand for long periods of time?
YES NO
11. Is it hard for you to get moving after you have been sitting or lying down?
12. Do you always walk with a limp?
13. Does your leg sometimes lock or give-way?
14. Do you have trouble getting in or out of a low chair?
15. Do you have trouble getting in or out of bed?
16. Do you kneel?
17. Do you pick up things from the floor?
18. Do you run at all?
19. Do you have trouble getting in or out of a car?
20. Have you stopped using public transportation because of your injury or arthritis?
 
 
How much are you bothered by problems you are now having using your arms or legs? Please pick one.
 
1. Not at All Bothered
 
2. A Little Bothered
 
3. Somewhat Bothered
 
4. Quite Bothered
 
5. Extremely Bothered
 
 
Comments (Optional):
   
 
 
ACTIVITIES USING YOUR HANDS
The following questions are about activities using your hands. If the question is true for you, please check "YES". If the question is not true for you, please check "NO".
YES NO
1. Do you have difficulty squeezing things?
2. Do you have difficulty making a tight fist?
3. Is it hard for you to put your hand in your pocket?
4. Do you have difficulty turning knobs or levers (for example, opening doors, rolling down car windows)?
5. Do you have trouble holding a book?
6. Do you have difficulty writing or typing?
7. Do you have trouble opening medicine bottles or jars?
 
 
How much are you bothered by problems you are now having using your hands? Please pick one.
 
1. Not at All Bothered
 
2. A Little Bothered
 
3. Somewhat Bothered
 
4. Quite Bothered
 
5. Extremely Bothered
 
 
Comments (Optional):
   
 
 
WORK AROUND YOUR HOME
These questions are about activities around your home, including such things as cooking, cleaning, maintenance, or repairs. If the question is true for you, please check "YES". If the question is not true for you, please check "NO".
YES NO
1. Do you need help with housework or yardwork?
2. Do you do as much housework or yardwork?
3. Do you do household chores but find that it takes more effort?
4. Do you mop or sweep or vacuum?
5. Is scrubbing a pan or dish difficult?
6. Do you need someone to cook for you?
7. Does it take you longer to do household chores?
8. Is it difficult for you to shop for groceries or other things?
9. Have you stopped doing car, house, maintenance repairs because of your injury or arthritis?
 
 
 
How much are you bothered by problems you are now having using your hands? Please pick one.
 
1. Not at All Bothered
 
2. A Little Bothered
 
3. Somewhat Bothered
 
4. Quite Bothered
 
5. Extremely Bothered
Share This Survey:          Survey Software Powered by QuestionPro Survey Software