Health Assessment Questionnaire (Haq) - British Columbia Ministry Of Health
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1
2HEALTH ASSESSMENT
QUESTIONNAIRE (HAQ)
Name
PHN
Date (yyyy / mm / dd)
1. For each category, please check the one response that best describes your abilities over the past week.
NO
SOME
MUCH
UNABLE
Dressing and Grooming
DIFFICULTY
DIFFICULTY
DIFFICULTY
TO DO
Dress yourself, including tying shoelaces and doing buttons
Shampoo your hair
Rising
Stand up from an armless chair
Get in and out of bed
Eating
Cut your meat
Lift a full cup or glass to your mouth
Open a new carton of milk
Walking
Walk outdoors on flat ground
Climb up five stairs
Hygiene
Wash and dry your entire body
Take a bath
Get on and off the toilet
Reach
Reach and get down a 5 lb object
(for example, a bag of sugar from just above your head)
Bend down to pick up clothing from the floor
Grip
Open car doors
Open jars which have been previously opened
Turn taps on and off
Activities
Run errands and shop
Get in and out of a car
Do chores such as vacuuming, housework or light gardening
PAGE 1 OF 2
HLTH 5383 2016/11/23
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Parent category: Medical