Functional Status Questionnaire

Physical function:
Basic activities of daily living (ADL)
During the past month have you had difficulty:
1.    Taking care of yourself‚ that is‚ eating‚ dressing or bathing?
2.    Moving in and out of a bed or chair?
3.    Walking indoors‚ such as around your home?
Intermediate ADL
4.    Walking several blocks?
5.    Walking one block or climbing one flight of stairs?
6.    Doing work around the house such as cleaning‚ light yard work‚ home maintenance?
7.    Doing errands‚ such as grocery shopping?
8.    Driving a car or using public transportation?
9.    Doing vigorous activities such as running‚ lifting heavy objects or participating in strenuous sports?
Responses: usually did with no difficulty (4)‚ some difficulty (3)‚ much difficulty (2)‚ usually did not do because of health (1)‚ usually did not do for other reasons (0).
Psychological function:
During the past month:
Mental health
10.Have you been a very nervous person?
11.Have you felt calm and peaceful?*
12.Have you felt downhearted and blue?
13.Were you a happy person?*
14.Did [Do] you feel so down in the dumps that nothing could cheer you up?
Responses: all of the time (1)‚ most of the time (2)‚ a good bit of the time (3)‚ some of the time (4)‚ a little of the time (5)‚ none of the time (6).
Social/role function:
During the past month have you: Work performance (for those employed‚ during the preceding month)
15.Done as much work as others in similar jobs?*
16.Worked for short periods of time or taken frequent rests because of your health?
17.Worked your regular number of hours?*
18.Done your job as carefully and accurately as others with similar jobs?*
19.Worked at your usual job‚ but with some changes because of your health?
20.Feared losing your job because of your health?
Responses: all of the time (1)‚ most of the time (2)‚ some of the time (3)‚ none of the time (4).
Social activity
21.Had difficulty visiting with relatives or friends?
22.Had difficulty participating in community activities‚ such as religious services‚ social activities‚ or volunteer work?
23.Had difficulty taking care of other people such as family members?
Responses: Usually did with no difficulty (4)‚ some difficulty (3)‚ much difficulty (2)‚ usually did not do because of health (1)‚ usually did not do for other reasons (0).
Quality of interaction
24.Isolated yourself from people around you?
25.Acted affectionate toward others?*
26.Acted irritable toward those around you?
27.Made unreasonable demands on your family and friends?
28.Gotten along well with other people?*
Responses: all of the time (1)‚ most of the time (2)‚ a good bit of the time (3)‚ some of the time (4)‚ a little of the time (5)‚ none of the time (6).
Single item questions:
29.Which of the following statements best describes your work situation during the past month? Responses: working full-time; working part-time; unemployed; looking for work; unemployed because of my health; retired because of my health; retired for some other reason.
30.During the past month‚ how many days did illness or injury keep you in bed all or most of the day? Response: 0–31 days.
31.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? Response: 0–31 days.
32.During the past month‚ how satisfied were you with your sexual relationships? Responses: very satisfied; satisfied; not sure; dissatisfied; very dissatisfied; did not have any sexual relationships.
33.How do you feel about your own health? Responses: very satisfied; satisfied; not sure; dissatisfied; very dissatisfied.
34.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? Responses: every day; several times a week; about once a week; two or three times a month; about once a month; not at all.
 
Physical function (activities of daily living or ADL)‚ psychological function‚ role function‚ social function‚ variety of performance measures
 
Scale (alpha)
Basic ADL (0.77 to 0.84)‚ IADL (0.82 to 0.89)‚ mental health (0.77 to 0.88)‚ social activity (0.65 to 0.83)‚ quality of social interaction (0.42 to 0.79)
 
An asterisk indicates items for which scores are reversed.
 
 

Jette‚ A.M.‚ Davies‚ A.R.‚ Cleary‚ P.D.‚ et al. (1986). The Functional Status Questionnaire: reliability and validity when used in primary care. Journal of General Internal Medicine‚ 1(3):143–149.

Jette‚ A.M.‚ Cleary‚ P.D. (1987). Functional disability assessment. Phys Ther‚ 67:1854–1859.

Rubenstein‚ L.V.‚ Calkins‚ D.R.‚ Young‚ R.T.‚ et al. (1989). Improving patient function: a randomized trial of functional disability screening. Ann Intern Med‚ 111:836–842.

Cleary‚ P.D.‚ Jette‚ A.M. (2000). Reliability and validity of the Functional Status Questionnaire. Qual Life Res‚ 9:747–753.

McDowell‚ Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires‚ Third Edition. OXFORD UNIVERSITY PRESS