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Key words: Childhood Health Assessment. Questionnaire (CHAQ) Child Health. Questionnaire (CHQ)
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Jan 19 2001 The Health Assessment Questionnaire (HAQ) was originally developed in 1978 by James F. Fries
The Health Assessment Questionnaire (HAQ) Disability Index
The Health Assessment Questionnaire (HAQ) was originally developed in 1978 by James F Fries MD and colleagues at Stanford University It was one of the first self-report functional status (disability) measures and has become the dominant instrument in many disease areas including arthritis
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The Health Assessment Questionnaire (HAQ) was originally developed in 1978 by James F Fries MD and colleagues at Stanford University It was one of the first self-report functional status (disability) measures and has become the dominant instrument in many disease areas including arthritis
HEALTH ASSESSMENT
QUESTIONNAIRE (HAQ)
NamePHNDate (yyyy / mm / dd)
Dressing and Grooming
Dress y ourself, including tying shoelaces and doing buttonsShampoo your hair
Rising
Stand up fr om an armless chair
Get in and out of bed
Eating
Cut y our meat
Lift a full cup or glass t o your mouth
Open a new carton of milk
Walking
Walk out doors on ?at ground
Climb up ?ve stairs
Hygiene
Wash and dr y your entire body
Take a ba th
Get on and o? the t oilet
ReachReach and get do wn a 5 lb object
(for e xample, a bag of sugar from just above your head)Bend do wn to pick up clothing from the ?oor
GripOpen car doors
Open jars which have been previously opened
Tur n taps on and o?
Activities
Run err ands and shop
Get in and out of a car
Do chor es such as vacuuming, housework or light gardeningNO SOME MUCH UNABLE
DIFFICULTY DIFFICULTY DIFFICULTY TO DO
1. For each category, please check the
one response that best describes your abilities over the past weekHLTH 5383 2016/11/23
PAGE 1 OF 2
HLTH 5383
PAGE 2 OF 2
NamePHN
2. Do y ou usually (more than 50% of the time) use the following aids or devices for any of the activities listed on page 1?
Check all that apply.
CanesWalker
Crut ches
Wheelchair/sc ooter
Raised t oilet seat
Bath sea t
Jar opener (for jars previously opened)
Special or built-up utensils
Special or built-up chair
Bath r ail
Long-handled applicanc e for reach
Other (specify)
3. Do y ou usually (more than 50% of the time) need help from another person for any of the following? Check all that apply.
Err ands and housework
Reaching
Dressing and g rooming
Gripping and opening things
Eating
Walk ing
Rising
Hy giene
4. Please cir cle the number, from 0 to 10, which indicates how much pain you have had in the past week because of your
arthritis, with 0 being "no pain" and 10 being "pain as bad as it could be".PAIN SC ALE RATING: 0 1 2 3 4 5 6 7 8 9 10
PATIENT CONSENT
Personal information on this form is collected under the authority of, and in accordance with, the British Columbia Pharmaceutical Services Act and
Freedom of Information and Protection of Privacy Act . It will not be disclosed to any persons without the patient's consent.The information you providewill be relevant to and used solely to (a) provide PharmaCare bene?ts for the medication requested, (b) to implement, monitor and evaluate this
and other Ministry programs, and (c) to manage and plan for the health system generally. If you have any questions about the collection or use of
this information, call Health Insurance BC from Vancouver at 1-604-683-7151 or from elsewhere in BC toll free at 1-800-663-7100 and ask to consult a
pharmacist concerning the Special Authority process.I authorize the prescriber to release to PharmaCare and in the Ministry of Health the information contained in this form and any other related
information in the prescriber's custody as required for adjudication, monitoring and evaluation.Patient's Signature Date
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