Health Assessment Questionnaire (HAQ) Disability Index Please try to answer each question, even if you do not think it is related to you at this time. There are no right or wrong answers. Please answer exactly as you think or feel. Thank-you. 1. ✔ Please check ( ) the ONE best answer for your abilities OVER THE PAST WEEK: DRESSING & GROOMING a. Dress yourself, including tying shoelaces and doing buttons? b. Shampoo your hair? ARISING c. Stand up from an armless chair? d. Get in and out of bed? EATING e. Cut your meat? f. Lift a full cup or glass to your mouth? g. Open a new milk carton? WALKING h. Walk outdoors on fat ground? i. Climb up fve steps? HYGIENE j. Wash and dry your entire body? k. Take a tub bath? l. Get on and off the toilet? REACH M. Reach and get a 5-lb object (such as a bag of sugar) from just above your head? N. Bend down and pick up clothing from the foor? Without Any With Some With Much Unable Difculty Difculty Difculty To Do Are you able to: Please check any AIDS OR DEVICES that you usually use for any of these activities: Cane Walker Crutches Wheelchair Please check any categories for which you need HELP FROM ANOTHER PERSON Dressing and Grooming Eating Arising Walking Devices used for dressing (button hook, zipper puller, etc) Built-up or special utensils Special or built up chair Other (specify): 1=0.125 7=0.875 13=1.625 19=2.375 2=0.25 8=1.0 14=1.75 20=2.5 3=0.375 9=1.125 15=1.875 21=2.625 4=0.5 10=1.25 16=2.0 22=2.75 5=0.625 11=1.375 17=2.125 23=2.875 6=0.75 12=1.5 18=2.25 24=3.0 HAQ PN FT SL GL AM CH For offce use only 0-0.5 Mild 0.5-1.0 Mild-Mod 1.0-1.5 Mod 1.5-2.0 Mod-Sev 2.0-3.0 Sev 41
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