WHO Disability Assessment Schedule

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Key Points

- This secure form will allow you to provide the information your GP team needs to get an idea of how your condition impacts your life.
 - This includes some questions about how your sympotms affect your thinking, commuinication, mobility and activities.
 - Your answers may not be seen immediately meaning this service is not suitable for seeking urgent or emergency care.
 - This form should only be used by someone over the age of 13.
 - When you are ready to complete your Questionnaire, click the "Answer WHODAS Questions" tab above.


Your Details:
DOB:
These questions relate to your general health.
How many Standard Drinks of alcohol do you have on average each week?
How much / what do you smoke each day (if anything)?
How would you like to enter your height and weight?
Your BMI is one indicator of a healthy weight.

Your BMI: Please provide your height and weight

The questions on this page and the following pages, known as the Organization Disability Assessment Schedule, assess the impact of your condition on your life.
They are a trademark of The World Health Organisation.

These questions are about your understanding and communication over the last 30 days
In the past 30 days, how much difficulty did you have in concentrating on doing something for ten minutes?
In the past 30 days, how much difficulty did you have in remembering to do important things?
In the past 30 days, how much difficulty did you have in analyzing and finding solutions to problems in day-to-day life?
In the past 30 days, how much difficulty did you have in learning a new task, for example, learning how to get to a new place?
In the past 30 days, how much difficulty did you have in generally understanding what people say?
In the past 30 days, how much difficulty did you have in starting and maintaining a conversation?
These questions are about your mobility (getting around) over the last 30 days
In the past 30 days, how much difficulty did you have in standing for long periods, such as 30 minutes?
In the past 30 days, how much difficulty did you have in standing up from sitting down?
In the past 30 days, how much difficulty did you have in moving around inside your home?
In the past 30 days, how much difficulty did you have in getting out of your home?
In the past 30 days, how much difficulty did you have in Walking a long distance, such as a kilometer (or equivalent)?
These questions are about your self-care over the last 30 days
In the past 30 days, how much difficulty did you have in washing your whole body?
In the past 30 days, how much difficulty did you have in getting dressed?
In the past 30 days, how much difficulty did you have in eating?
In the past 30 days, how much difficulty did you have in staying by yourself for a few days?
These questions are about how you got along with people over the last 30 days
In the past 30 days, how much difficulty did you have in dealing with people you do not know?
In the past 30 days, how much difficulty did you have in maintaining a friendship?
In the past 30 days, how much difficulty did you have in getting along with people who are close to you?
In the past 30 days, how much difficulty did you have in making new friends?
In the past 30 days, how much difficulty did you have in sexual activities?
These questions are about your household life activities over the last 30 days
In the past 30 days, how much difficulty did you have in taking care of your household responsibilities?
In the past 30 days, how much difficulty did you have in doing most important household tasks well?
In the past 30 days, how much difficulty did you have in getting all of the household work done that you needed to do?
In the past 30 days, how much difficulty did you have in getting your household work done as quickly as needed?
These questions are about your work / school life activities over the last 30 days
Because of your health condition, in the past 30 days, how much difficulty did you have in your day-to-day work/school?
Because of your health condition, in the past 30 days, how much difficulty did you have in doing your most important work/school tasks well?
Because of your health condition, in the past 30 days, how much difficulty did you have in getting all of the work done that you need to do?
Because of your health condition, in the past 30 days, how much difficulty did you have in getting your work done as quickly as needed?
These questions are about your participation in society over the last 30 days
In the past 30 days, how much of a problem did you have in joining in community activities (for example, festivities, religious, or other activities) in the same way as anyone else can?
In the past 30 days, how much of a problem did you have because of barriers or hindrances around you?
In the past 30 days, how much of a problem did you have living with dignity because of the attitudes and actions of others?
In the past 30 days, how much time did you spend on your health condition or its consequences?
In the past 30 days, how much have you been emotionally affected by your health condition?
In the past 30 days, how much has your health been a drain on the financial resources of you or your family?
In the past 30 days, how much of a problem did your family have because of your health problems?
In the past 30 days, how much of a problem did you have in doing things by yourself for relaxation or pleasure?
Are you happy for a clinician to see your responses and complete your review without further discussion (if appropriate)?

Questions, concerns or additional comments: