Functional Assessment Survey



First M.I. Last

Date of Birth    

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:?

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

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?

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)?

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?

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?     

     7b. Did you have a lot of energy?     

     7c. Have you felt downhearted and blue?     

     7d. Have you been a happy person?     

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

     8b. Climbing several flights of stairs

     8c. Walking several blocks