Additional file 1
Disability Index
(Scleroderma Health Assessment Questionnaire)
Disability Index
(Scleroderma Health Assessment Questionnaire)
Visit number: 1 2 3
Date: ______/______/______
Research ID number: ____________________
Please check the answer that best describes your usual abilities in the past 7 days.
Are you able to:
Without
any Difficulty
With Some
Difficulty
With Much
Difficulty
Unable
to do
Dress yourself, including tying
shoelaces & doing buttons?
Office
Use
Dressing &
Grooming
Shampoo your hair?
Arising
Stand up from an armless
straight chair?
Get in and out of bed?
Eating
Cut your meat?
Lift a full glass to your mouth?
Open a new milk carton?
Walk outdoors on flat ground?
Walking
Climb up five stairs?
Wash and dry your entire body
Hygiene
Take a bath
Get on and off the toilet
Are you able to:
Reach and get down a heavy
Object (such as bag of sugar,
or a large book) from just over
Without
any Difficulty
With Some
Difficulty
With Much
Difficulty
Unable
to do
Office
Use
Reach
your head?
Bend down and pick up
clothing off the floor ?
Open car doors?
Grip
Open jars that have been
Previously opened?
Turn taps on and off?
Activity
Run errands and shop?
Get in and out of a car?
Do household cleaning such
as vacuuming or sweeping?
FOR OFFICE USE:
Transfer the worst score
Without any
difficulty= 0
With some
Difficulty=1
With much
Difficulty=2
Unable to
Do=3
TOTAL=