Functional Status Questionnaire – FSQ

During the past month, have you had difficulty taking care of yourself, that is, eating, dressing or bathing?

During the past month, have you had difficulty moving in and out of a bed or chair?

During the past month, have you had difficulty walking indoors, such as around your home?

During the past month, have you had difficulty walking several blocks?

During the past month, have you had difficulty walking one block or climbing one flight of stairs?

During the past month, have you had difficulty doing work around the house such as cleaning, light yard work, home maintenance?

During the past month, have you had difficulty doing errands, such as grocery shopping?

During the past month, have you had difficulty driving a car or using public transportation?

During the past month, have you had difficulty doing vigorous activities such as running, lifting heavy objects or participating in strenuous sports?

During the past month, have you been a very nervous person?

During the past month, have you felt calm and peaceful?

During the past month, have you felt downhearted and blue?

During the past month, were you a happy person?

During the past month, did you feel so down in the dumps that nothing could cheer you up?

During the past month, have you done as much work as others in similar jobs?

During the past month, have you worked for short periods of time or taken frequent rests because of your health?

During the past month, have you worked your regular number of hours?

During the past month, have you done your job as carefully and accurately as others with similar jobs?

During the past month, have you worked at your usual job, but with some changes because of your health?

During the past month, have you feared losing your job because of your health?

During the past month, have you had difficulty visiting with relatives or friends?

During the past month, have you had difficulty participating in community activities, such as religious services, social activities, or volunteer work?

During the past month, have you had difficulty taking care of other people such as family members?

During the past month, have you isolated yourself from people around you?

During the past month, have you acted affectionate toward others?

During the past month, have you acted irritable toward those around you?

During the past month, have you made unreasonable demands on your family and friends?

During the past month, have you gotten along well with other people?