| On average, it takes 30 minutes to complete the Neuro-QOL survey | |||
| 1 | In the past 7 days | I can keep up with my family responsibilities | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 2 | In the past 7 days | I have trouble meeting the needs of my family | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 3 | In the past 7 days | I am able to do all of my regular family activities | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 4 | In the past 7 days | I have to limit my regular family activities | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 5 | In the past 7 days | I am able to do all of the family activities that people expect me to do | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 6 | In the past 7 days | I am able to do all of the family activities that I want to do | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 7 | In the past 7 days | I am able to maintain my friendships as much as I would like | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 8 | In the past 7 days | I am able to socialize with my friends | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 9 | In the past 7 days | I am able to do all of my regular activities with friends | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 10 | In the past 7 days | I have to limit my regular activities with friends | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 11 | In the past 7 days | I can do everything for my friends that I want to do | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 12 | In the past 7 days | I am able to do all of the activities with friends that people expect me to do | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 13 | In the past 7 days | I feel limited in my ability to visit friends | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 14 | In the past 7 days | I am able to do all of the activities with friends that I want to do | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 15 | In the past 7 days | I feel limited in the amount of time I have to visit friends | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 16 | In the past 7 days | I have to limit the things I do for fun at home (like reading, listening to music, etc.) | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 17 | In the past 7 days | I can keep up with my social commitments | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 18 | In the past 7 days | I am able to do all of my regular leisure activities | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 19 | In the past 7 days | I have to limit my hobbies or leisure activities | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 20 | In the past 7 days | I am able to do my hobbies or leisure activities | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 21 | In the past 7 days | I am able to do all of the community activities that I want to do | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 22 | In the past 7 days | I am able to do all of the leisure activities that people expect me to do | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 23 | In the past 7 days | I have to do my hobbies or leisure activities for shorter periods of time than usual for me | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 24 | In the past 7 days | I have to limit social activities outside my home | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 25 | In the past 7 days | I have trouble keeping in touch with others | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 26 | In the past 7 days | I am able to participate in leisure activities | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 27 | In the past 7 days | I can do all the leisure activities that I want to do | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 28 | In the past 7 days | I am able to do all of the community activities that people expect me to do | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 29 | In the past 7 days | I am able to go out for entertainment as much as I want | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 30 | In the past 7 days | I have to limit the things I do for fun outside my home | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 31 | In the past 7 days | I am doing fewer social activities with groups of people than usual for me | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 32 | In the past 7 days | I am able to perform my daily routines | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 33 | In the past 7 days | I am able to run errands without difficulty | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 34 | In the past 7 days | I can keep up with my work responsibilities (include work at home) | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 35 | In the past 7 days | I am able to do all of my usual work (include work at home) | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 36 | In the past 7 days | I have trouble taking care of my regular personal and household responsibilities | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 37 | In the past 7 days | I am accomplishing as much as usual at work for me (include work at home) | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 38 | In the past 7 days | My ability to do my work is as good as it can be (include work at home) | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 39 | In the past 7 days | I can do everything for work that I want to do (include work at home) | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 40 | In the past 7 days | I have trouble doing my regular chores or tasks | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 41 | In the past 7 days | I am able to do all of the work that people expect me to do (include work at home) | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 42 | In the past 7 days | I am limited in doing my work (include work at home) | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 43 | In the past 7 days | I have to do my work for shorter periods of time than usual for me (include work at home) | 5 = Never 4 = Rarely 3 = Sometimes 3 = Often 1 = Always |
| 44 | In the past 7 days | I am able to work at a volunteer job outside my home | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 45 | In the past 7 days | I am limited in working at a volunteer job outside my home | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 46 | In the past 7 days | I am able to do all of my usual work | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 47 | In the past 7 days | I am limited in doing my work | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 48 | In the past 7 days | I am able to do all of the work that people expect me to do | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 49 | In the past 7 days | I have to do my work for shorter periods of time than usual for me | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 1 | In the past 7 days | I feel that my family is disappointed in my ability to socialize with them | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 2 | In the past 7 days | I am disappointed in my ability to meet the needs of my family | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 3 | In the past 7 days | I am bothered by my limitations in regular family activities | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 4 | In the past 7 days | I feel good about my ability to do things for my family | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 5 | In the past 7 days | I am satisfied with my ability to meet the needs of those who depend on me | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 6 | In the past 7 days | I am satisfied with my ability to do things for my family | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 7 | In the past 7 days | I am bothered if I have to depend on my family for help | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 8 | In the past 7 days | I am satisfied with my current level of activity with family members | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 9 | In the past 7 days | I am bothered if I have to depend on others for help | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 10 | In the past 7 days | I feel that my friends are disappointed in my ability to socialize with them | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 11 | In the past 7 days | I am disappointed in my ability to meet the needs of my friends | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 12 | In the past 7 days | I am disappointed in my ability to do things for my friends | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 13 | In the past 7 days | I am disappointed in my ability to socialize with friends | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 14 | In the past 7 days | I am bothered by limitations in my regular activities with friends | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 15 | In the past 7 days | I am disappointed in my ability to keep in touch with others | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 16 | In the past 7 days | I am bothered if I have to depend on my friends for help | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 17 | In the past 7 days | I wish I could visit my friends more often | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 18 | In the past 7 days | I am satisfied with my ability to do things for my friends | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 19 | In the past 7 days | I am happy with how much I do for my friends | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 20 | In the past 7 days | I am satisfied with my current level of activities with my friends | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 21 | In the past 7 days | I am satisfied with the amount of time I spend visiting friends | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 22 | In the past 7 days | I feel that others are disappointed in my ability to do community activities | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 23 | In the past 7 days | I am disappointed in my ability to socialize with my family | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 24 | In the past 7 days | I am disappointed in my ability to do leisure activities | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 25 | In the past 7 days | I am bothered by limitations in doing my hobbies or leisure activities | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 26 | In the past 7 days | I wish I could do more social activities with groups of people | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 27 | In the past 7 days | I am satisfied with my ability to do things for fun at home (like reading, listening to music, etc.) | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 28 | In the past 7 days | I wish I could do more social activities outside my home | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 29 | In the past 7 days | I am satisfied with my ability to do leisure activities | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 30 | In the past 7 days | I am satisfied with my ability to do all of the leisure activities that are really important to me | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 31 | In the past 7 days | I am satisfied with my ability to do all of the community activities that are really important to me | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 32 | In the past 7 days | I am satisfied with the amount of time I spend doing leisure activities | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 33 | In the past 7 days | I am satisfied with my ability to do things for fun outside my home | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 34 | In the past 7 days | I am satisfied with my current level of social activity | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 35 | In the past 7 days | I feel that I am disappointing other people at work | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 36 | In the past 7 days | I am disappointed in my ability to perform my daily routines | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 37 | In the past 7 days | I am disappointed in my ability to work (include work at home) | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 38 | In the past 7 days | I am bothered by limitations in performing my daily routines | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 39 | In the past 7 days | I am disappointed in my ability to take care of personal and household responsibilities | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 40 | In the past 7 days | I am bothered by limitations in performing my work (include work at home) | 5 = Not at all 4 = A little bit 3 = Somewhat 2 = Quite a bit 1 = Very much |
| 41 | In the past 7 days | I am satisfied with my ability to run errands | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 42 | In the past 7 days | I am satisfied with my ability to perform my daily routines | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 43 | In the past 7 days | I am satisfied with my ability to work (include work at home) | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 44 | In the past 7 days | I am satisfied with my ability to do the work that is really important to me (include work at home) | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 45 | In the past 7 days | I am satisfied with my ability to take care of personal and household responsibilities | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 46 | In the past 7 days | I am satisfied with my ability to do household chores or tasks | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 47 | In the past 7 days | I am satisfied with how much of my work I can do (include work at home) | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 48 | In the past 7 days | I am satisfied with the amount of time I spend doing work (include work at home) | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 49 | In the past 7 days | I am satisfied with the amount of time I spend performing my daily routines | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 50 | In the past 7 days | I am satisfied with my ability to work | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| 51 | In the past 7 days | I am bothered by limitations in performing my work | 1 = Not at all 2 = A little bit 3 = Somewhat 4 = Quite a bit 5 = Very much |
| On average, it takes 30 minutes to complete the Neuro-QOL survey | ||||
| 1 | PF Screen Items 2 & 3 | How much DIFFICULTY do you currently have sitting down on and standing up from a chair with arms with your walking aid? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 2 | PF Screen Items 2 & 3 | How much DIFFICULTY do you currently have walking on uneven surfaces (e.g., grass, dirt road or sidewalk) with your walking aid? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 3 | PF Screen Items 2 & 3 | How much DIFFICULTY do you currently have sitting down or standing up from a low, soft couch with your walking aid? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 4 | PF Screen Items 3 & 4 | How much DIFFICULTY do you currently have sitting down on an armless straight chair, using a wheelchair? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 5 | PF Screen Items 3 & 4 | How much DIFFICULTY do you currently have propelling / driving a wheelchair for at least 15 minutes? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 6 | PF Screen Items 2 & 3 | How much DIFFICULTY do you currently have going up and down three flights of stairs inside, using a handrail with your walking aid? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 7 | PF Screen Items 2 & 3 | How much DIFFICULTY do you currently have going up and down a flight of stairs inside, using a handrail with your walking aid? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 8 | PF Screen Items 2 & 3 | How much DIFFICULTY do you currently have getting into and out of a truck, bus, shuttle van, or sport utility vehicle with your walking aid? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 9 | PF Screen items 3 & 4 | How much DIFFICULTY do you currently have getting into and out of a truck, bus, shuttle van, or sport utility vehicle from a wheelchair? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 10 | PF Screen Items 2 & 3 | How much DIFFICULTY do you currently have descending 3-5 stairs without a handrail with your walking aid? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 11 | PF Screen Items 2 & 3 | Are you able to go for a walk of at least 15 minutes with your walking aid? | 5 = Without any difficulty 4 = With a little difficulty 3 = With some difficulty 2 = With much difficulty 1 = Unable to do |
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| 12 | PF Screen Items 2 & 3 | Are you able to get in and out of a car with your walking aid? | 5 = Without any difficulty 4 = With a little difficulty 3 = With some difficulty 2 = With much difficulty 1 = Unable to do |
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| 13 | PF Screen Items 3 & 4 | Are you able to get in and out of a car from a wheelchair? | 5 = Without any difficulty 4 = With a little difficulty 3 = With some difficulty 2 = With much difficulty 1 = Unable to do |
|
| Which of the 4 Statements Best Describes You? | |
| I never use a walking device or wheelchair. | 1 |
| I use a cane, walker or other walking device at least some of the time, but I never use a wheelchair. | 2 |
| I use a walking device at least some of the time and a wheelchair at least some of the time. | 3 |
| I use a wheelchair all of the time. I never walk. | 4 |
| 1 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have standing up from an armless straight chair (e.g., dining room chair)? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 2 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have sitting down on an armless straight chair (e.g., dining room chair)? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 3 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have sitting down on and standing up from a chair with arms? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 4 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have moving from sitting at the side of the bed to lying down on your back? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 5 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have moving from lying on your back to sitting on the side of the bed? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 6 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have standing up from a low, soft couch? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 7 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have sitting down on a low, soft couch? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 8 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have going up and down a flight of stairs inside, using a handrail? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 9 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have walking on uneven surfaces (e.g., grass, dirt road or sidewalk)? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 10 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have opening a window above shoulder height, while standing? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 11 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have walking around one floor of your home? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 12 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have getting into and out of a truck, bus, shuttle van, or sport utility vehicle? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 13 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have running 45 minutes? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 14 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have running up and down an incline? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 15 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have walking 45 minutes on an even surface? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 16 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have taking a 20-minute brisk walk, without stopping to rest? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 17 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have walking on a slippery surface, outdoors? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 18 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have getting into and out of a kneeling position? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 19 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have using an escalator? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 20 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have crossing the road at a 4-lane traffic light with curbs? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 21 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have climbing stairs step over step without a handrail? (alternating feet)? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 22 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have going up and down three flights of stairs inside, using a handrail? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 23 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have walking in a dark room without falling? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 24 | PF Screen Items 1, 2 or 3 | How much DIFFICULTY do you currently have walking in a busy place (e.g., crowded store) without losing your balance? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
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| 25 | PF Screen Items 1, 2 or 3 | Are you able to push open a heavy door? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
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| 26 | PF Screen Items 1, 2 or 3 | Are you able to get in and out of a car? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
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| 27 | PF Screen Items 1, 2 or 3 | Are you able to run at a fast pace for two miles? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
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| 28 | PF Screen Items 1, 2 or 3 | Are you able to go for a walk of at least 15 minutes? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
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| 29 | PF Screen Items 1, 2 or 3 | Are you able to run or jog for 10 minutes? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
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| 30 | PF Screen Items 1, 2 or 3 | Are you able to step up and down curbs? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
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| 31 | PF Screen Items 1, 2 or 3 | Are you able to get up off the floor from lying on your back without help? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
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| 32 | PF Screen Items 1, 2 or 3 | Are you able to get out of bed into a chair? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
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| 33 | PF Screen Items 1, 2 or 3 | Are you able to run errands and shop? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
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| 34 | PF Screen Items 1, 2 or 3 | Are you able to jump up and down? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
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| 35 | PF Screen Items 1, 2 or 3 | Are you able to run for 5 minutes? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 36 | PF Screen Items 1, 2 or 3 | How difficult is it for you to go for a walk of at least 15 minutes? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 37 | PF Screen Items 1, 2 or 3 | Are you able to get on and off the toilet? | 5 = Without any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 1 | How much DIFFICULTY do you currently have using a fork to eat a meal? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 2 | How much DIFFICULTY do you currently have applying spreads to bread using a knife? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 3 | How much DIFFICULTY do you currently have using a spoon to eat a meal? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 4 | How much DIFFICULTY do you currently have putting on a pullover shirt? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 5 | How much DIFFICULTY do you currently have taking off a pullover shirt? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 6 | How much DIFFICULTY do you currently have removing wrappings from small objects? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 7 | How much DIFFICULTY do you currently have chopping or slicing vegetables (e.g., onions or peppers)? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 8 | How much DIFFICULTY do you currently have reaching behind your back to put a belt through a loop? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 9 | Male only item | How much DIFFICULTY do you currently have shaving your neck and face safely and thoroughly with an electric razor? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
|
| 10 | Female only item | How much DIFFICULTY do you currently have shaving your legs and underarms safely and thoroughly with an electric razor? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
|
| 11 | How much DIFFICULTY do you currently have playing cards or Bingo or other light recreational activities? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 12 | How much DIFFICULTY do you currently have picking up a gallon carton of milk with one hand and setting it on the table? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 13 | How much DIFFICULTY do you currently have pounding a nail with a hammer to hang a picture? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 14 | How much DIFFICULTY do you currently have holding a screw and screwing it in tight with a manual screwdriver? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 15 | How much DIFFICULTY do you currently have opening medications or vitamin containers (e.g., childproof containers, small bottles)? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 16 | How much DIFFICULTY do you currently have cleaning yourself after a bowel movement? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 17 | How much DIFFICULTY do you currently have pulling up and fastening your pants after a bowel movement? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 18 | How much DIFFICULTY do you currently have putting a Band-Aid or gauze pad on yourself? | 5 = No Difficulty 4 = A Little Difficulty 3 = Some Difficulty 2 = A Lot of Difficulty 1 = Can't Do |
||
| 19 | Are you able to open previously opened jars? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 20 | Are you able to brush your teeth? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 21 | Are you able to press with your index finger (for example ringing a doorbell)? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 22 | Are you able to squeeze a new tube of toothpaste? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 23 | Are you able to hold a plate full of food? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 24 | Are you able to remove something from your back pocket? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 25 | Are you able to wash your face with a washcloth? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 26 | Are you able to water a house plant? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 27 | Are you able to open a can with a hand can opener? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 28 | Are you able to open and close a zipper? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 29 | Are you able to turn a key in a lock? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 30 | Are you able to write with a pen or pencil? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 31 | Are you able to pull on trousers? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 32 | Are you able to button your shirt? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 33 | Are you able to wash and dry your body? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 34 | Are you able to change the bulb in a table lamp? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 35 | Are you able to cut a piece of paper with scissors? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 36 | Are you able to pick up coins from a table top? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 37 | Are you able to shampoo your hair? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 38 | Are you able to trim your fingernails? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 39 | Are you able to cut your toe nails? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 40 | Are you able to tie your shoelaces? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 41 | Are you able to bend down and pick up clothing from the floor? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 42 | Are you able to change a light bulb overhead? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 43 | Are you able to open a tight or new jar? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| 44 | Are you able to make a phone call using a touch tone key-pad? | 5 = Without Any Difficulty 4 = With a Little Difficulty 3 = With Some Difficulty 2 = With Much Difficulty 1 = Unable to Do |
||
| On average, it takes 30 minutes to complete the Neuro-QOL survey | |||
| 1 | Lately | I felt happy about the future | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 2 | Lately | I was able to enjoy life | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 3 | Lately | I felt a sense of purpose in my life | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 4 | Lately | I could laugh and see the humor in situations | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 5 | Lately | I was able to be at ease and feel relaxed | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 6 | Lately | I looked forward with enjoyment to upcoming events | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 7 | Lately | Many areas of my life were interesting to me | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 8 | Lately | I felt emotionally stable | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 9 | Lately | I was able to relax | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 10 | Lately | I felt lovable | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 11 | Lately | I felt confident | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 12 | Lately | I felt hopeful | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 13 | Lately | I had a good life | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 14 | Lately | I had a sense of well-being | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 15 | Lately | My life was satisfying | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 16 | Lately | I had a sense of balance in my life | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 17 | Lately | My life had meaning | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 18 | Lately | My life was peaceful | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 19 | Lately | My life was worth living | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 20 | Lately | My life had purpose | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 21 | Lately | I was living life to the fullest | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 22 | Lately | I felt cheerful | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 23 | Lately | In most ways my life was close to my ideal. | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 24 | Lately | I had good control of my thoughts. | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 25 | Lately | I had good control of my emotions. | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 26 | Lately | Even when things were going badly, I still had hope. | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 27 | Lately | I felt loved and wanted. | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 1 | In the past 7 days | I felt lonely even when I was with other people | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 2 | In the past 7 days | I felt worthless | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 3 | In the past 7 days | I felt that I had nothing to look forward to | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 4 | In the past 7 days | I felt helpless | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 5 | In the past 7 days | I withdrew from other people | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 6 | In the past 7 days | I felt that everything I did was an effort | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 7 | In the past 7 days | I felt that nothing could cheer me up | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 8 | In the past 7 days | I was critical of myself for my mistakes | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 9 | In the past 7 days | I felt like crying | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 10 | In the past 7 days | I felt sad | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 11 | In the past 7 days | I felt that I wanted to give up on everything | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 12 | In the past 7 days | I felt lonely | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 13 | In the past 7 days | I felt depressed | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 14 | In the past 7 days | I felt discouraged about the future | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 15 | In the past 7 days | I wished I were dead and away from it all | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 16 | In the past 7 days | I thought about suicide | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 17 | In the past 7 days | I had crying spells | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 18 | In the past 7 days | I found that things in my life were overwhelming | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 19 | In the past 7 days | I felt unhappy | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 20 | In the past 7 days | I felt unloved | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 21 | In the past 7 days | I felt I had no reason for living | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 22 | In the past 7 days | I felt that others would be better off if I were dead | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 23 | In the past 7 days | I felt hopeless | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 24 | In the past 7 days | I felt that nothing was interesting | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 25 | In the past 7 days | I felt pessimistic | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 26 | In the past 7 days | I had trouble keeping my mind on what I was doing | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 27 | In the past 7 days | I felt that my life was empty | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 28 | In the past 7 days | I felt emotionally exhausted | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 29 | In the past 7 days | I felt like I needed help for my depression | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 30 | In the past 7 days | I had trouble enjoying things that I used to enjoy | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 1 | In the past 7 days | I was afraid of what the future holds for me | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 2 | In the past 7 days | I felt fearful about my future | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 3 | In the past 7 days | I felt anxious | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 4 | In the past 7 days | I worried about my physical health | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 5 | In the past 7 days | I felt like I needed help for my anxiety | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 6 | In the past 7 days | I had a racing or pounding heart | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 7 | In the past 7 days | I felt nervous when my normal routine was disturbed | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 8 | In the past 7 days | I had trouble falling asleep | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 9 | In the past 7 days | I had sudden feelings of panic | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 10 | In the past 7 days | My sleep was restless | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 11 | In the past 7 days | I was easily startled | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 12 | In the past 7 days | I felt fidgety | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 13 | In the past 7 days | I felt something awful would happen | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 14 | In the past 7 days | I felt worried | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 15 | In the past 7 days | I felt nervous when I was left alone | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 16 | In the past 7 days | I felt terrified | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 17 | In the past 7 days | I suddenly felt scared for no reason | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 18 | In the past 7 days | I worried about dying | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 19 | In the past 7 days | I was preoccupied with my worries | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 20 | In the past 7 days | My worries overwhelmed me | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 21 | In the past 7 days | I felt shy | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 22 | In the past 7 days | I felt nervous | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 23 | In the past 7 days | Many situations made me worry | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 24 | In the past 7 days | I had trouble sleeping | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 25 | In the past 7 days | I had trouble relaxing | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 26 | In the past 7 days | I felt uneasy | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 27 | In the past 7 days | I felt tense | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| 28 | In the past 7 days | I had difficulty calming down | 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always |
| On average, it takes 30 minutes to complete the Neuro-QOL survey | |||
| 1 | How much DIFFICULTY do you currently have writing notes to yourself, such as appointments or 'to do' lists? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 2 | How much DIFFICULTY do you currently have composing a brief note or e-mail to someone? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 3 | How much DIFFICULTY do you currently have understanding familiar people during ordinary conversations? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 4 | How much DIFFICULTY do you currently have understanding family and friends on the phone? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 5 | How much DIFFICULTY do you currently have making yourself understood to familiar people over the phone? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 6 | How much DIFFICULTY do you currently have making yourself understood to other people during ordinary conversations? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 7 | How much DIFFICULTY do you currently have describing something that has happened to you so that others can understand you? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 8 | How much DIFFICULTY do you currently have carrying on a conversation with a small group of familiar people (e.g., family or a few friends)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 9 | How much DIFFICULTY do you currently have putting words together to form grammatically correct sentences? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 10 | How much DIFFICULTY do you currently have organizing what you want to say? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 11 | How much DIFFICULTY do you currently have speaking clearly enough to use the telephone? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 12 | How much DIFFICULTY do you currently have reading simple material (e.g., a menu or the TV or radio guide)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 13 | How much DIFFICULTY do you currently have reading the newspaper or magazine? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 14 | How much DIFFICULTY do you currently have understanding information on food labels? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 15 | How much DIFFICULTY do you currently have keeping track of time (eg., using a clock)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 16 | How much DIFFICULTY do you currently have checking the accuracy of financial documents, (e,g., bills, checkbook, or bank statements)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 17 | How much DIFFICULTY do you currently have counting the correct amount of money when making purchases? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 18 | How much DIFFICULTY do you currently have doing calculations in your head while shopping (e.g., 30% off, etc.)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 19 | How much DIFFICULTY do you currently have using information on the bill to figure out where to call if you have a problem? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 20 | How much DIFFICULTY do you currently have carrying on a conversation with a familiar person in a noisy environment (e.g., at a party or meeting)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 21 | How much DIFFICULTY do you currently have following a series of dialing instructions (e.g., a recorded message "Press 1 for...")? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 22 | How much DIFFICULTY do you currently have reading and following complex instructions (e.g., directions for a new medication)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 23 | How much DIFFICULTY do you currently have looking up a phone number or address in the phone book? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 24 | How much DIFFICULTY do you currently have planning for and keeping appointments that are not part of your weekly routine, (e.g., a therapy or doctor appointment, or a social gathering with friends and family)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 25 | How much DIFFICULTY do you currently have managing your time to do most of your daily activities? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 26 | How much DIFFICULTY do you currently have planning an activity several days in advance (e.g., a meal, trip, or visit to friends)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 27 | How much DIFFICULTY do you currently have taking care of complicated tasks like managing a checking account or getting appliances fixed? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 28 | How much DIFFICULTY do you currently have keeping important personal papers such as bills, insurance documents and tax forms organized? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 29 | How much DIFFICULTY do you currently have handling an unfamiliar problem (e.g., getting the refrigerator fixed)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 30 | How much DIFFICULTY do you currently have planning for and completing regularly scheduled weekly tasks, such as taking out the trash or doing laundry? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 31 | How much DIFFICULTY do you currently have getting things organized? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 32 | How much DIFFICULTY do you currently have planning what to do in the day? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 33 | How much DIFFICULTY do you currently have explaining how to do something involving several steps to another person? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 34 | How much DIFFICULTY do you currently have using a local street map to locate a new store or doctor's office? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 35 | How much DIFFICULTY do you currently have dialing familiar numbers such as a family member or doctor (without losing your place or misdialing)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 36 | How much DIFFICULTY do you currently have reading a long book (over 100 pages) over a number of days? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 37 | How much DIFFICULTY do you currently have remembering to take medications at the appropriate time? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 38 | How much DIFFICULTY do you currently have remembering where things were placed or put away (e.g., keys)? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 39 | How much DIFFICULTY do you currently have remembering a list of 4 or 5 errands without writing it down? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 40 | How much DIFFICULTY do you currently have learning new tasks or instructions? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 41 | How much DIFFICULTY do you currently have using a map to tell where to go? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 42 | How much DIFFICULTY do you currently have understanding pictures that explain how to assemble something? | 5=None 4=A Little 3=Somewhat 2=A lot 1=Cannot Do | |
| 43 | In the past 7 days | I got confused, for example, I did not know where I was | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 44 | In the past 7 days | I had difficulty paying attention for a long period of time | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 45 | In the past 7 days | I felt like my mind went blank | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 46 | In the past 7 days | I made simple mistakes more easily | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 47 | In the past 7 days | After I made a mistake, I got stuck and couldn’t figure out a new way to go | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 48 | In the past 7 days | I had trouble recognizing my mistakes right away | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 49 | In the past 7 days | I had trouble saying what I mean in conversations with others | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 50 | In the past 7 days | I was told that I start talking before the other person finishes | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 51 | In the past 7 days | I was told that I repeat myself | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 52 | In the past 7 days | I was a worse listener than usual | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 53 | In the past 7 days | Words I wanted to use seemed to be on the “tip of my tongue” | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 54 | In the past 7 days | I had trouble finding the right word(s) to express myself | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 55 | In the past 7 days | I used the wrong word when I referred to an object | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 56 | In the past 7 days | I communicated by gestures, for example, moving my head, pointing or sign language | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 57 | In the past 7 days | My speech was understood only by a few people who know me well | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 58 | In the past 7 days | I had to repeat myself so others could understand me | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 59 | In the past 7 days | I slurred or stuttered while speaking | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 60 | In the past 7 days | I had to talk very slowly to make myself understood | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 61 | In the past 7 days | My speech was difficult for others to understand | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 62 | In the past 7 days | I had trouble recalling the name of an object | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 63 | In the past 7 days | I had trouble recognizing familiar words on a page | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 64 | In the past 7 days | I had to read something several times to understand it | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 65 | In the past 7 days | I had trouble keeping track of what I was doing if I was interrupted | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 66 | In the past 7 days | I had difficulty doing more than one thing at a time | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 67 | In the past 7 days | I had trouble remembering whether I did things I was supposed to do, like taking a medicine or buying something I needed | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 68 | In the past 7 days | I had trouble remembering new information, like phone numbers or simple instructions | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 69 | In the past 7 days | I walked into a room and forgot what I meant to get or do there | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 70 | In the past 7 days | I had trouble remembering the name of a familiar person | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 71 | In the past 7 days | I forgot to do things like turn off the stove or turn on my alarm clock" | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 72 | In the past 7 days | I had trouble thinking clearly | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 73 | In the past 7 days | I reacted slowly to things that were said or done | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 74 | In the past 7 days | I had trouble forming thoughts | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 75 | In the past 7 days | My thinking was slow | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 76 | In the past 7 days | My thinking was confused | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 77 | In the past 7 days, | I had to work really hard to pay attention or I would make a mistake | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 78 | In the past 7 days, | I had trouble adding or subtracting numbers in my head | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 79 | In the past 7 days, | I made mistakes when writing down phone numbers | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 80 | In the past 7 days, | I had trouble concentrating | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 81 | In the past 7 days, | I had trouble spelling words correctly when writing | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 82 | In the past 7 days, | I had trouble keeping track of the day or date | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 83 | In the past 7 days, | I had trouble getting started on very simple tasks | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 84 | In the past 7 days, | I had trouble making decisions | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 85 | In the past 7 days, | When I had something to do that takes a long time, I had trouble deciding where to start | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 86 | In the past 7 days, | I had trouble planning out steps of a task | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 87 | In the past 7 days, | I needed medical instructions repeated because I could not keep them straight | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| 88 | In the past 7 days, | When I was reading I needed to use a ruler or my finger to keep track of which line I was on | 1=Never 2=Rarely (once) 3=Sometimes (two or three times) 4=Often (about once a day) 5=Very often (several times a day) |
| On average, it takes 30 minutes to complete the Neuro-QOL survey | |||
| 1 | In the past 7 days | I felt too sad to do things with friends | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 2 | In the past 7 days | I become anxious when I go back to the hospital or clinic | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 3 | In the past 7 days | I worry about how my health will affect my future. | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 4 | In the past 7 days | I felt sad. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 5 | In the past 7 days | I felt like eating | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 6 | In the past 7 days | Because of my health, I worry about having a boyfriend or girlfriend. | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 7 | In the past 7 days | I thought that my life was bad. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 8 | In the past 7 days | I was bored. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 9 | In the past 7 days | I felt lonely. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 10 | In the past 7 days | I worry about getting a good job because of my medical condition | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 11 | In the past 7 days | I felt frustrated | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 12 | In the past 7 days | Being angry made it hard for me to be with my friends | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 13 | In the past 7 days | It was hard to do schoolwork because I was angry | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 14 | In the past 7 days | I felt angry. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 15 | In the past 7 days | I was so mad that I felt like throwing something. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 16 | In the past 7 days | I was so mad that I felt like hitting something. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 17 | In the past 7 days | I was so mad that I felt like yelling at someone. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 18 | In the past 7 days | I was so mad that I felt like breaking things. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 19 | In the past 7 days | I was so mad that I acted grouchy towards other people. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 20 | In the past 7 days | I get nervous more easily than other people | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 21 | In the past 7 days | I worried when I was away from my family | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 22 | In the past 7 days | I felt afraid to go out alone | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 23 | In the past 7 days | Being worried made it hard for me to be with my friends | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 24 | In the past 7 days | It was hard to do schoolwork because I was nervous or worried | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 25 | In the past 7 days | I got scared easily. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 26 | In the past 7 days | I felt afraid. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 27 | In the past 7 days | I was worried that I might die. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 28 | In the past 7 days | I worried when I was at home. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 29 | In the past 7 days | I felt worried. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 30 | In the past 7 days | I felt nervous. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 31 | In the past 7 days | I was less interested in doing things I usually enjoy | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 32 | In the past 7 days | My mood swings from good feelings to bad feelings | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 33 | In the past 7 days | I had trouble sleeping. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 34 | In the past 7 days | It was hard for me to care about anything | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 35 | In the past 7 days | I wanted to be by myself. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 36 | In the past 7 days | It was hard for me to have fun. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 37 | In the past 7 days | I felt that no one loved me. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 38 | In the past 7 days | I cried more often than usual. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 39 | In the past 7 days | I felt alone. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 40 | In the past 7 days | I felt like I couldn't do anything right. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 41 | In the past 7 days | I felt everything in my life went wrong. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 42 | In the past 7 days | I felt too sad to do my schoolwork | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 43 | In the past 7 days | I worry that my health might get worse | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 44 | In the past 7 days | Because of my health, I worry about being able to go to college | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 45 | In the past 7 days | Because of my health, I worry about getting a job to support myself | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 46 | In the past 7 days | I worry about doing well in school | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 1 | In the past 7 days | I got along with my classmates. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 2 | In the past 7 days | I wished I had more friends. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 3 | In the past 7 days | I liked being around other kids my age. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 4 | In the past 7 days | I had trouble getting along with other kids my age. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 5 | In the past 7 days | I had trouble getting along with my family. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 6 | In the past 7 days | I was mean to other people. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 7 | In the past 7 days | I teased other kids. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 8 | In the past 7 days | I got along with my parents or guardians. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 9 | In the past 7 days | I felt accepted by other kids my age. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 10 | In the past 7 days | I was able to talk openly with my friends. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 11 | In the past 7 days | I felt close to my friends. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 12 | In the past 7 days | I was able to count on my friends. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 13 | In the past 7 days | I felt loved by my parents or guardians. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 14 | In the past 7 days | I was happy at home. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 15 | In the past 7 days | My parents or guardians spent enough time with me. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 16 | In the past 7 days | I got along well with my teachers. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 17 | In the past 7 days | I felt different from other kids my age. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 18 | In the past 7 days | I shared with other kids (food, games, pens, etc.). | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 19 | In the past 7 days | I was able to stand up for myself. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 20 | In the past 7 days | I felt comfortable with others my age. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 21 | In the past 7 days | My teachers accepted me. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 22 | In the past 7 days | My teachers respected me. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 23 | In the past 7 days | I worried about losing friends. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 24 | In the past 7 days | I got into fights (hitting, kicking, pushing) with other kids. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 25 | In the past 7 days | My parents or guardians seem to know what's important to me. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 26 | No timeframe | I think I have fewer friends than other people my age. | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 27 | No timeframe | I feel lonely. | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 28 | In the past 7 days | I was happy with the friends I had. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 29 | In the past 7 days | My friends ignored me. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 30 | In the past 7 days | I felt comfortable talking with my friends. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 31 | In the past 7 days | I wanted to spend time with my friends. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 32 | In the past 7 days | I spent time with my friends. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 33 | In the past 7 days | I did things with other kids my age. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 34 | In the past 7 days | I felt comfortable talking with my parents or guardians. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 35 | In the past 7 days | Because of my health, I missed out on important activities. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 36 | In the past 7 days | My friends and I helped each other out. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 37 | In the past 7 days | I argued with my parents or other adults. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 38 | In the past 7 days | I had fun with my friends. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| On average, it takes 30 minutes to complete the Neuro-QOL survey | |
| Which of the 4 Statements Best Describes You? | |
| I never use a walking device or wheelchair. | 1 |
| I use a cane, walker or other walking device at least some of the time, but I never use a wheelchair. | 2 |
| I use a walking device at least some of the time and a wheelchair at least some of the time. | 3 |
| I use a wheelchair all of the time. I never walk. | 4 |
| 1 | In the past 7 days | I could keep my balance while walking for 30 minutes | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 2 | In the past 7 days | I could get down on my knees without holding on to something. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 3 | In the past 7 days | I could keep up when I played with other kids. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 4 | In the past 7 days | I could walk for 15 minutes | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 5 | In the past 7 days | I could walk between rooms | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 6 | In the past 7 days | I could run as fast as others my own age. | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 7 | In the past 7 days | I could get on and off the toilet. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 8 | In the past 7 days | I could get on and off the toilet without using my arms. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 9 | In the past 7 days | I could get on and off a low chair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 10 | In the past 7 days | I could get in and out of an adult-sized chair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 11 | In the past 7 days | I could get on and off a chair without using my arms. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 12 | In the past 7 days | I could walk for 30 minutes | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 13 | In the past 7 days | I could get up from the floor by myself | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 14 | In the past 7 days | I could sit on a bench without support for 15 minutes | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 15 | In the past 7 days | I could sit on a bench without back support for 30 minutes | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 16 | In the past 7 days | I could keep my balance while walking for 15 minutes | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 17 | In the past 7 days | I could stand on my tiptoes to reach for something | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 18 | In the past 7 days | I could stand on my tiptoes to put something (e.g., 5 lb bag of sugar) on a shelf | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 19 | In the past 7 days | I could turn my head all the way to the side to look at someone or something | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 20 | In the past 7 days | I fall down easily | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 21 | In the past 7 days | I could walk on slightly uneven surfaces (such as cracked pavement) | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 22 | In the past 7 days | I lose my balance easily | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 23 | In the past 7 days | I have trouble keeping up with other kids my age when walking | 0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much |
| 24 | In the past 7 days | I could walk on rough, uneven surfaces (such as lawns, gravel driveway) | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 25 | In the past 7 days | I could walk up and down ramps or hills | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 26 | In the past 7 days | I could walk up and down curbs | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 27 | In the past 7 days | I could run for 15 minutes | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 28 | In the past 7 days | I could run for 30 minutes. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 29 | In the past 7 days | I could get in and out of a bus | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 30 | In the past 7 days | I could get in and out of a car. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 31 | In the past 7 days | I could walk across the room. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 32 | In the past 7 days | I could walk while wearing a backpack full of books. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 33 | In the past 7 days | I could bend over to pick something up. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 34 | In the past 7 days | I could do sports that others my age can do. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 35 | In the past 7 days | I could do exercise that others my age can do. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 36 | In the past 7 days | I could carry bags (such as shopping bags) while going up a full flight of stairs | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 37 | In the past 7 days | I could carry bags (such as shopping bags) while going down a full flight of stairs | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 38 | In the past 7 days | I could ride a bicycle | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 39 | In the past 7 days | I could walk up 2-3 stairs | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 1 | In the past 7 days | I was able to open small containers like snack bags or vitamins (regular screw top) | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 2 | In the past 7 days | I was able to wash and dry my hands without help | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 3 | In the past 7 days | I was able to use my fingers to point to something | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 4 | In the past 7 days | I was able to take off my socks | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 5 | In the past 7 days | I was able to put on and fasten my pants by myself | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 6 | In the past 7 days | I was able to button and unbutton my shirt | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 7 | In the past 7 days | I was able to unzip my pants | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 8 | In the past 7 days | I was able to hold a full cup of water in my hand. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 9 | In the past 7 days | I was able to wash my hair without help | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 10 | In the past 7 days | I was able to lift a cup of water to my mouth without spilling | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 11 | In the past 7 days | I was able to use a spoon to bring food up to my mouth | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 12 | In the past 7 days | I was able to use a knife to spread butter or jelly on bread | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 13 | In the past 7 days | I was able to wipe myself thoroughly after using the toilet | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 14 | In the past 7 days | I was able to pull my pants back up after using the toilet | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 15 | In the past 7 days | I was able to hold a plate full of food | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 16 | In the past 7 days | I was able to carry a tray of food in a cafeteria or restaurant | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 17 | In the past 7 days | I was able to pick up a gallon of milk with one hand and set it on the table | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 18 | In the past 7 days | I was able to get in and out of a tub without help | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 19 | In the past 7 days | I was able to cut a piece of paper in half with scissors | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 20 | In the past 7 days | I was able to style my hair by myself | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 21 | In the past 7 days | I was able to cover my nose when sneezing | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 22 | In the past 7 days | I was able to use a computer mouse | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 23 | In the past 7 days | I was able to open a can of soda | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 24 | In the past 7 days | I was able to take a shower by myself. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 25 | In the past 7 days | I was able to take a bath by myself. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 26 | In the past 7 days | I was able to change positions in my bed. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 27 | In the past 7 days | I was able to write a short note by using a pencil or pen. | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 28 | In the past 7 days | I was able to communicate with friends using e-mail or text messaging | 0 = Never 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always |
| 29 | In the past 7 days | I was able to make a phone call using a touch tone key-pad | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 30 | In the past 7 days | I was able to get out of bed by myself. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 31 | In the past 7 days | I was able to get into bed by myself. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 32 | In the past 7 days | I was able to put on my shoes by myself. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 33 | In the past 7 days | I was able to open a jar by myself. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 34 | In the past 7 days | I was able to put toothpaste on my toothbrush by myself. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 35 | In the past 7 days | I was able to brush my teeth by myself. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 36 | In the past 7 days | I was able to pull open heavy doors. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 37 | In the past 7 days | I was able to open the rings in school binders. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 38 | In the past 7 days | I was able to dry my back with a towel. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 39 | In the past 7 days | I was able to put on my clothes by myself. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 40 | In the past 7 days | I was able to zip up my clothes. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 1 | In the past 7 days | With a walking aid | I could walk for 15 minutes | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 2 | In the past 7 days | With a walking aid | I could walk for 30 minutes | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 3 | In the past 7 days | With a walking aid | I could walk on slightly uneven surfaces (cracked pavement) | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 4 | In the past 7 days | With a walking aid | I could walk on rough, uneven surfaces (lawns, gravel driveway) | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 5 | In the past 7 days | With a walking aid | I could walk up and down inclines or ramps | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 6 | In the past 7 days | With a walking aid | I could walk up and down curbs | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 7 | In the past 7 days | With a walking aid | I could open and close inside or outside doors to walk between rooms |
0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 8 | In the past 7 days | With a walking aid | I could walk within a room | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 9 | In the past 7 days | With a walking aid | I could walk across the room. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 10 | In the past 7 days | With a walking aid | I could walk up stairs without holding on to anything. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 11 | In the past 7 days | With a walking aid | I could get in and out of a car. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 1 | In the past 7 days | I could move up and down curbs using a wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 2 | In the past 7 days | I could move up and down inclines or ramps using a wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 3 | In the past 7 days | I could move on rough, uneven surfaces (lawns, gravel driveway) using a wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 4 | In the past 7 days | I could move between my wheelchair and another seat such as a chair or bed | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 5 | In the past 7 days | I could move around within a room, including making turns in my wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 6 | In the past 7 days | I could manage getting on and off the tub bench from a wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 7 | In the past 7 days | I could manage getting on and off the toilet from a wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 8 | In the past 7 days | I could stand up from an armless straight chair using my wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 9 | In the past 7 days | I could move on slightly uneven surfaces (cracked pavement) | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 10 | In the past 7 days | I could move for 30 minutes using a wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 11 | In the past 7 days | I could park a wheelchair in a narrow space (e.g., in an elevator) | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 12 | In the past 7 days | I could back out of an elevator in a wheelchair if there was no room to turn around | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 13 | In the past 7 days | I could do a wheelie (e.g., popping front wheels off the floor and balancing on back wheels) using my wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 14 | In the past 7 days | I could reach for a high object from my wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 15 | In the past 7 days | I could reverse direction in my wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 16 | In the past 7 days | I could open a door that faced away from my wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 17 | In the past 7 days | I could open a door that was facing my wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 18 | In the past 7 days | I could lock and unlock my wheelchair brakes | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 19 | In the past 7 days | I could manage the armrests on my wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 20 | In the past 7 days | I could manage the footrests on my wheelchair. | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| 21 | In the past 7 days | I could move for 15 minutes using a wheelchair | 0 = With no trouble 1 = With a little trouble 2 = With some trouble 3 = With a lot of trouble |
| File Type | application/vnd.ms-excel |
| Author | victord |
| Last Modified By | curriem |
| File Modified | 2008-02-27 |
| File Created | 2007-05-10 |