Here are two sets of Functionality Questions provided by Dr. Jason and Dr. Hartz Please provide Suggestions for Edits/Additions BELOW the these sections - do not directly edit the authors questions. Thanks
Hartz
Questions about your health and ability to function
INSTRUCTIONS: This questionnaire asks about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Please answer every question by marking one number. If you are unsure about how to answer, please give the best answer you can. You do not need to answer any questions that you feel uncomfortable answering.
15. In general, would you say your health is: Excellent 1
Very good 2
Good 3
Fair 4
Poor 5
16. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
Yes, limited a lot
Yes, limited a little
No, not limited at all
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf 1 2 3
Climbing several flights of stairs 1 2 3
17. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
Yes No
Accomplished less than you would like 1 2
Were limited in the kind of work or other activities 1 2
Jason
78. Which statement best describes your fatigue/energy related illness during the last 6 months? (Check one)
I am not able to work or do anything, and I am bedridden.
I can walk around the house, but I cannot do light housework.
I can do light housework, but I cannot work part-time.
I can only work part-time at work or on some family responsibilities.
I can work full time, but I have no energy left for anything else.
I can work full time and finish some family responsibilities but I have no energy left
for anything else.
I can do all work or family responsibilities without any problems with my energy.
88. In the past 4 weeks, approximately how many hours per week have you spent doing:
89. In the past 4 weeks, have you had to reduce the number of hours you previously spent (prior to your illness) on occupational, social or family activities because of your health or problems with fatigue/energy?
Yes No (Skip to Question 90)
89b. Before your fatigue/energy related illness, approximately how many hours did you used to spend on:
90. Please rate the amount of energy you had available yesterday, using a scale from 1 to 100 where 1 = no energy and 100 = your pre-illness energy level
91. Please rate the amount of energy you expended (used) yesterday, using a scale from 1 to 100 where 1 = no energy and 100 = your pre-illness energy expended
92. Please rate the amount of fatigue you had yesterday, using a scale from 1 to 100 where 1 = no fatigue and 100 = severe fatigue
93. For the past week, please rate the amount of energy you had available using a scale from 1 to 100 where 1=no energy and 100=your pre-illness energy level
94. For the past week, please rate the amount of energy you have expended (used) using a scale from 1 to 100 where 1 = no energy and 100 = your pre-illness energy expended
95. For the past week, please rate the amount of fatigue you have had using a scale from 1 to 100 where 1 = no fatigue and 100 = severe fatigue
VERNON
The following items are about activities you might do during a typical day. Does your health now limit you in these activities and if so, how much? Check the appropriate box
Yes limited a lot Yes limited a little No not limited at all
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? Yes No
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
Yes No
During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal
social activities with family, friends, neighbors, or groups?
____ Not at all ____ Slightly ____ Moderately ___ Quite a bit ___ Extremely
Hartz
Questions about your health and ability to function
INSTRUCTIONS: This questionnaire asks about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Please answer every question by marking one number. If you are unsure about how to answer, please give the best answer you can. You do not need to answer any questions that you feel uncomfortable answering.
15. In general, would you say your health is: Excellent 1
Very good 2
Good 3
Fair 4
Poor 5
16. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
Yes, limited a lot
Yes, limited a little
No, not limited at all
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf 1 2 3
Climbing several flights of stairs 1 2 3
17. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
Yes No
Accomplished less than you would like 1 2
Were limited in the kind of work or other activities 1 2
Jason
78. Which statement best describes your fatigue/energy related illness during the last 6 months? (Check one)
I am not able to work or do anything, and I am bedridden.
I can walk around the house, but I cannot do light housework.
I can do light housework, but I cannot work part-time.
I can only work part-time at work or on some family responsibilities.
I can work full time, but I have no energy left for anything else.
I can work full time and finish some family responsibilities but I have no energy left
for anything else.
I can do all work or family responsibilities without any problems with my energy.
88. In the past 4 weeks, approximately how many hours per week have you spent doing:
- Household related activities? hours per week
- Social/Recreational related activities? hours per week
- Family related activities? hours per week
- Work related activities? hours per week
89. In the past 4 weeks, have you had to reduce the number of hours you previously spent (prior to your illness) on occupational, social or family activities because of your health or problems with fatigue/energy?
Yes No (Skip to Question 90)
89b. Before your fatigue/energy related illness, approximately how many hours did you used to spend on:
- Household related activities? hours per week
- Social/Recreational related activities? hours per week
- Family related activities? hours per week
- Work related activities? hours per week
90. Please rate the amount of energy you had available yesterday, using a scale from 1 to 100 where 1 = no energy and 100 = your pre-illness energy level
91. Please rate the amount of energy you expended (used) yesterday, using a scale from 1 to 100 where 1 = no energy and 100 = your pre-illness energy expended
92. Please rate the amount of fatigue you had yesterday, using a scale from 1 to 100 where 1 = no fatigue and 100 = severe fatigue
93. For the past week, please rate the amount of energy you had available using a scale from 1 to 100 where 1=no energy and 100=your pre-illness energy level
94. For the past week, please rate the amount of energy you have expended (used) using a scale from 1 to 100 where 1 = no energy and 100 = your pre-illness energy expended
95. For the past week, please rate the amount of fatigue you have had using a scale from 1 to 100 where 1 = no fatigue and 100 = severe fatigue
VERNON
The following items are about activities you might do during a typical day. Does your health now limit you in these activities and if so, how much? Check the appropriate box
Yes limited a lot Yes limited a little No not limited at all
- Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
- Lifting or carrying groceries
- Climbing several flights of stairs
- Climbing one flight of stairs
- Bending, kneeling, or stooping
- Walking more than a mile
- Walking several blocks
- Walking one block
- Bathing or dressing yourself
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? Yes No
- Cut down the amount of time you spent on work or other activities
- Accomplished less than you would like
- Were limited in the kind of work or other activities
- Had difficulty performing the work or other activities (for example, it took extra effort)
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
Yes No
- Cut down the amount of time you spent on work or other activities
- Accomplished less than you would like
- Didn't do work or other activities as carefully as usual
During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal
social activities with family, friends, neighbors, or groups?
____ Not at all ____ Slightly ____ Moderately ___ Quite a bit ___ Extremely