Number | Item |
---|---|
1. | I am comfortable moving around my house. |
2. | I am comfortable moving around my community. |
3. | I am able to make longer trips. |
4. | I am comfortable with how my self-care needs are met (e.g., dressing, feeding, toileting, bathing) |
5. | I freely engage in work that is necessary or important to me (such as paid or voluntary work, housework or studying, etc.) |
6. | I am satisfied with my capacity for work |
7. | I am satisfied with my capacity to meet my needs and the needs of any dependents. |
8. | I am able to participate in social and religious activities as I want to (e.g., attending church/mosque services, prayer, community functions/parties) |
9. | I am comfortable socializing with family, friends and/or acquaintances |
10. | I have a role in my family which meets my needs (Family means people with whom you live and/or relatives with whom you don’t live but see on a regular basis) |
11. | I have a role in my family which meets the needs of my family members (Family means people with whom you live and/or relatives with whom you don’t live but see on a regular basis) |
12. | I am satisfied with the role that I hold in my community. |
13. | In general, I am comfortable with my personal relationships. |
14. | In general, I am comfortable with my relationship with my husband/partner. |
15. | In general, I am comfortable with my relationship with my children. |
16. | In general, I am comfortable with my relationship with friends/other family members. |
17. | In general, I am comfortable with myself in the company of others. |
18. | During the past month, I have often felt down, depressed or hopeless. |
19. | In general, I feel hope for the future. |
20. | In general, I am satisfied with myself. |
21. | In general, I am satisfied with my health. |
22. | In general, I am satisfied with my life. |