Health Assessment Questionnaire
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1
2HEALTH ASSESSMENT QUESTIONNAIRE (HAQ)
Date:
Patient Name:
Please tick the one response which best describes your usual abilities over the past week
Without ANY With SOME
With MUCH UNABLE
difficulty
difficulty
difficulty
to do
1. DRESSING and GROOMING
Are you able to:
a. Dress yourself, including tying
shoelaces and doing buttons?
--------
b. Shampoo your hair?
2. RISING
Are you able to:
a. Stand up from an armless
straight chair?
--------
b. Get in and out of bed?
3. EATING
Are you able to:
a. Cut your meat?
b. Lift a full cup or glass to your mouth?
--------
c. Open a new carton of milk
(or soap powder)?
4. WALKING
Are you able to:
a. Walk outdoors on flat ground?
b. Climb up five steps?
PLEASE TICK ANY AIDS OR DEVICES THAT YOU USUALLY USE FOR ANY OF THESE
ACTIVITIES:
Cane (W)
Walking frame(W)
Built-up or special utensils (E)
Crutches (W)
Wheelchair (W)
Special or built-up chair (A)
Devices used for dressing (button hooks, zipper pull, shoe horn)
Other (specify)..........................................................................................................
PLEASE TICK ANY CATEGORIES FOR WHICH YOU USUALLY NEED HELP FROM ANOTHER
PERSON:
Dressing and Grooming
Eating
Rising
Walking
ID
Page 1
For office use only
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