Functional Status Questionnaire – FSQ

Taking care of yourself, that is, eating, dressing or bathing?

Moving in and out of a bed or chair?

Walking indoors, such as around your home?

Walking several blocks?

Walking one block or climbing one flight of stairs?

Doing work around the house such as cleaning, light yard work, home maintenance?

Doing errands, such as grocery shopping?

Driving a car or using public transportation?

Doing vigorous activities such as running, lifting heavy objects or participating in strenuous sports?

Have you been a very nervous person?

Have you felt calm and peaceful?

Have you felt downhearted and blue?

Were you a happy person?

Did you feel so down in the dumps that nothing could cheer you up?

Done as much work as others in similar jobs?

Worked for short periods of time or taken frequent rests because of your health?

Worked your regular number of hours?

Done your job as carefully and accurately as others with similar jobs?

Worked at your usual job, but with some changes because of your health?

Feared losing your job because of your health?

Had difficulty visiting with relatives or friends?

Had difficulty participating in community activities, such as religious services, social activities, or volunteer work?

Had difficulty taking care of other people such as family members?

Isolated yourself from people around you?

Acted affectionate toward others?

Acted irritable toward those around you?

Made unreasonable demands on your family and friends?

Gotten along well with other people?

Which of the following statements best describes your work situation during the past month?

During the past month, how many days did illness or injury keep you in bed all or most of the day?

During the past month, how many days did you cut down on the things you usually do for one-half day or more because of your own illness or injury?

During the past month, how satisfied were you with your sexual relationships?

How do you feel about your own health?

During the past month, about how often did you get together with friends or relatives, such as going out together, visiting in each other’s homes, or talking on the telephone?