Health Assessment Questionnaire Page 2
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1
2Please 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
5. HYGIENE
Are you able to:
a. Wash and dry your entire body?
b. Take a bath?
--------
c. Get on and off the toilet?
6. REACH
Are you able to:
a. Reach and get down a 5 lb object
(e.g. a bag of potatoes) from just
above your head?
--------
b. Bend down to pick up clothing
off the floor?
7. GRIP
Are you able to:
a. Open car doors?
b. Open jars which have been
--------
previously opened?
c. Turn taps on and off?
8. ACTIVITIES
Are you able to:
a. Run errands and shop?
b. Get in and out of a car?
--------
c. Do chores such as vacuuming,
housework or light gardening?
PLEASE TICK ANY AIDS OR DEVICES THAT YOU USUALLY USE FOR ANY OF THESE
ACTIVITIES:
HAQ
0 0.0
1 0.125
Raised toilet seat (H)
Bath seat (H)
Bath rail (H)
2 0 .250
3 0 .375
Long handled appliances for reach (R)
4 0 .500
5 0.625
6 0 .750
Jar opener (for jars previously opened) (G)
7 0 .875
8 1.00
9 1.125
Other (specify)
10 1.250
11 1.375
12 1.500
13 1.625
PLEASE TICK ANY CATEGORIES FOR WHICH YOU USUALLY NEED HELP FROM ANOTHER
14 1.750
PERSON:
15 1.875
16 2.000
17 2.125
Hygiene
Gripping and opening things
18 2.250
19 2.375
Reach
Errands and housework
20 2.500
21 2.625
22 2.750
23 2.875
ID
Page 2
24 3.000
For office use only
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Parent category: Medical