Health assessment questionnaire¹⁷

Patient Label			Date
We are interested in learning how your illness affects your ability to function in daily life. Please feel free to add any comments at the end of this form. PLEASE TICK ONE RESPONSE WHICH BEST DESCRIBES YOUR USUAL ABILITIES OVER THE PAST WEEK:
	Without ANY difficulty	With SOME difficulty	With MUCH difficulty	Unable to do
	Score = 0	Score = 1	Score = 2	Score= 3
1. DRESSING AND GROOMING - Are you able to
Dress yourself, including tying shoelaces and doing buttons?
Shampoo your hair?
2. RISING - Are you able to
Stand up from an armless straight chair?
Get in and out of bed?
3. EATING - Are you able to
Cut your meat?
Lift a full cup or glass to your mouth?
Open a new carton of milk (or soap powder)?
4. WALKING - Are you able to
Walk outdoors on flat ground?
Climb up five steps?
PLEASE TICK AIDS OR DEVICES THAT YOU USUALLY USE FOR ANY OF THESE ACTIVITIES:
Walking stick		Crutches
Devices for dressing e.g. buttonhook, zipper pull, long handled shoe horn		Special or built-up chair Wheelchair
Walking frame		Other (please specify)
Built-up or special utensils
PLEASE TICK ANY CATEGORIES FOR WHICH YOU USUALLY NEED HELP FROM ANOTHER PERSON:
Dressing and grooming	Rising	Eating	Walking
	Without ANY difficulty	With SOME difficulty	With MUCH difficulty	Unable to do
	Score = 0	Score = 1	Score = 2	Score= 3
5. HYGIENE - Are you able to
Wash and dry your entire body?
Take a bath?
Get on and off the toilet?
6. REACH - Are you able to
Reach and get down a 5lb object (e.g. a bag of potatoes) from above your head?
Bend down to pick up clothing from the floor?
7. GRIP - Are you able to
Open car doors?
Open jars which have been previously opened?
Turn taps on and off?
8. ACTIVITIES - Are you able to
Run errands and shop?
Get in and out of a car?
Do chores such as vacuuming, housework or light gardening?
PLEASE TICK AIDS OR DEVICES THAT YOU USUALLY USE FOR ANY OF THESE ACTIVITIES:
Raised toilet seat	Jar opener (for jars previously opened)		Long handled appliances for reach
Bath seat	Bath rail		Other (please specify)
PLEASE TICK ANY CATEGORIES FOR WHICH YOU USUALLY NEED HELP FROM ANOTHER PERSON:
Hygiene	Reach	Gripping and opening things		Errands and housework
SCORING OF HAQ Add the maximum score for each of the 8 sections and divide by 8 to give a score between 0-3. If aid/device or help is needed the score for that activity automatically = 2 (unless 3 has already been ticked.) Normal function = 0 Most affected function = 3