Disability Assessment Form

World Health Organization Disability Assessment Schedule (WHODAS)

This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.

Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, check one response.

In the past 30 days, how much difficulty did you have in:

Understanding and communicating

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Concentrating on doing something for ten minutes? *

Remembering to do important things? *

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Analyzing and finding solutions to problems in day-to-day life? *

Learning a new task, for example, learning how to get to a new place? *

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Generally understanding what people say? *

Starting and maintaining a conversation? *

Getting around

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Standing for long periods, such as 30 minutes? *

Standing up from sitting down? *

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Moving around inside your home? *

Getting out of your home? *

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Walking a long distance, such as a kilometer (or equivalent)? *

Self-care

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Washing your whole body? *

Getting dressed? *

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Eating? *

Staying by yourself for a few days? *

Getting along with people

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Dealing with people you do not know? *

Maintaining a friendship? *

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Getting along with people who are close to you? | None Mild Moderate Severe Extreme/Cannot Do *

Making new friends? *

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Sexual activities? *

Life activities-Household

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Taking care of your household responsibilities? *

Doing most important household tasks well? *

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Getting all of the household work done that you needed to do? *

Getting your household work done as quickly as needed? *

Life activities-School/Work

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Your day-to-day work/school? *

Doing your most important work/school tasks well? *

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Getting all of the work done that you need to do? *

Getting your work done as quickly as needed? *

Participation in society

How much of a problem did you have in joining in community activities (for example, festivities, religious, or other activities) in the same way as anyone else can? *

How much of a problem did you have because of barriers or hindrances around you? *

How much of a problem did you have living with dignity because of the attitudes and actions of others? *

How much time did you spend on your health condition or its consequences? *

How much have you been emotionally affected by your health condition? *

How much has your health been a drain on the financial resources of you or your family? *

How much of a problem did your family have because of your health problems? *

How much of a problem did you have in doing things by yourself for relaxation or pleasure? *

After form submission you will be requested to create a login and password to access member only information and benefits.

Mental Health Evaluation

World Health Organization Disability Assessment Schedule (WHODAS)

In the past 30 days, how much difficulty did you have in:

Understanding and communicating

Getting around

Self-care

Getting along with people

Life activities-Household

Life activities-School/Work

Participation in society

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