Your Daily Activities
PATIENT INSTRUCTIONS: Indicate your response by selecting one button per question.
Does your health limit you in these activities?
The following items are activities you might do during a typical day. Does your health limit you in these activities? (Select an answer that best reflects your situation.)
Current Health Rating
Which one of the following phrases best describes you at this time?
How many times have you fallen in the last 6 months?
Are you taking any medications?
How many prescribed medications are you taking?
How many over-the-counter medications are you taking?
How many herbs and vitamins are you taking?
Patient Instructions: Do you have any of the following illnesses at the present time, and if so, how much does it interfere with your activities: Not at All, A Little, or A Great Deal?
Have you lost weight involuntarily over the past 6 months?
If yes, how much?
INSTRUCTIONS: These questions are about how you have been feeling within the past month. Please select an answer that best reflects your situation.
How much of the time during the past month:
INSTRUCTIONS: People sometimes look to others for companionship, assistance or other types of support. How often is each of the following kinds of support available to you if you need it? (Select an answer that best reflects your situation.)
Please answer the following questions about your religious beliefs and/or involvement. Select the answer that best reflects your situation.
The following section contains 3 statements about your religious belief or experience. Please select the extent to which each statement is true or not true for you.
Daily Activities: Older Americans Resources and Services (OARS) IADL: Fillenbaum, G.G., et al., 1981
Physical Activities: Medical Outcomes Study (MOS) Physical Health: Stewart A.L., et al., 1992
Current Health Rating: Karnofsky Self-Reported Performance Rating Scale: Loprinzi, C.L., et al., 1994
Your Health: Older Americans Resources and Services (OARS) Physical Health Section: Fillenbaum, G.G., et al., 1981
Health Questionnaire: MHI-17: Stewart and Ware, 1992
Social Activities: Medical Outcomes Study (MOS) Social Activity Limitations Measure: Sherbourne, C.D., et al., 1991
Social Support: Medical Outcomes Study (MOS) Social Support Survey: Emotional/Informational and Tangible subscales: Sherbourne, C.D., et al., 1991
Spirituality/Religion: DUREL – Duke University Religion Index – Koenig et al., 1997
Your Feelings: Mahoney et al., 1994; LASA – Locke et al., 2007