Functional Assessment Survey

CINET

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Name

First	M.I.	Last
*Required *No Special Characters		*Required *No Special Characters

Date of Birth  *Required *Valid Date of Birth Required (format MM/DD/YYYY)

1. Do you have any serious health problems?

       Yes (if no leave unchecked and skip to question 2)

2. In general, would you say your overall health is:?

excellent very good good fair poor

3. How much bodily pain have you had during the past 4 weeks?

none very mild mild moderate severe very severe

4. During the past 4 weeks, how much difficulty did you have doing your work or other regular daily activites as a result of your physical health?

none at all a little bit some quite a bit could not do daily work

5. During the past 4 weeks, to what extent have you accomplished less than you would like in your work or other daily activities as a result of emotional problems (such as feeling depressed or anxious)?

none at all slightly moderately extremely

6. During the past 4 weeks, to what extent have your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?

none at all slightly moderately quite a bit extremely

7. These questions are about how you feel and how things have been with you during the past 4 weeks. Fore each question, please give the one answer that comes closest to the way you hav been feeling. How much of the time during the past 4 weeks...

     7a. Have you felt calm and peaceful?     

          all of the time most of the time a good bit of the time some of the time a little of the time none of the time

     7b. Did you have a lot of energy?     

          all of the time most of the time a good bit of the time some of the time a little of the time none of the time

     7c. Have you felt downhearted and blue?     

          all of the time most of the time a good bit of the time some of the time a little of the time none of the time

     7d. Have you been a happy person?     

          all of the time most of the time a good bit of the time some of the time a little of the time none of the time

8. The following items are about activites you might do during a typical day. Does your health limit you in these activities? If so, how much?

     8a. Lifting or carrying groceries

          Yes limited a lot Yes limited a little No, not limited at all

     8b. Climbing several flights of stairs

          Yes limited a lot Yes limited a little No, not limited at all

     8c. Walking several blocks

          Yes limited a lot Yes limited a little No, not limited at all