WHODAS - eSignature


12-item version, self-administered


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 done the following activities. For each question, please circle only one response.


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



Standing for long periods such as 30
S2 Taking care of your household
S3 Learning a new task, for example,
learning how to get to a new place?
S4 How much of a problem did you have
joining in community activities (for
example, festivities, religious or other
activities) in the same way as anyone
else can?
S5 How much have you been emotionally
affected by your health problems?
S6 Concentrating on doing something for
ten minutes?
S7 Walking a long distance such as a
kilometre [or equivalent]?
S8 Washing your whole body?
S9 Getting dressed?
S10 Dealing with people you do not know?
S11 Maintaining a friendship?
S12 Your day-to-day work?



H1 Overall, in the past 30 days, how many days were these
difficulties present?
Record number of days ____
H2 In the past 30 days, for how many days were you totally unable
to carry out your usual activities or work because of any health
Record number of days ____
H3 In the past 30 days, not counting the days that you were totally
unable, for how many days did you cut back or reduce your
usual activities or work because of any health condition?
Record number of days ____

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: WHODAS - eSignature
lock iconUnique Document ID: 7812dd55c42d5016c3f36d1b460d1424019f7bce
Timestamp Audit
February 1, 2022 4:54 am CDTWHODAS - eSignature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP