748 Assessment Measures
 ClinicianUse
Only
Numeric scores assigned to each of the items: 1 2 3 4 5 
Raw Item 
Score 
Raw 
Domain 
Score 
Average 
Domain 
Score In the last 30 days, how much difficulty did you have in: 
Life activities ͶHousehold  
D5.1 Taking care of your household responsibilities?  None Mild Moderate Severe Extreme or 
cannot do  
 
____ 
20 
  
____ 
5 
 D5.2 Doing most important household tasks well?  None Mild Moderate Severe Extreme or 
cannot do  
D5.3 Getting all of the household work done that you 
needed to do?  None Mild Moderate Severe Extreme or 
cannot do  
D5.4 Getting your household work done as quickly as 
needed?  None Mild Moderate Severe Extreme or 
cannot do  
Life activities ͶSchool/Work   
If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5 ʹD5.8, below. 
Otherwise, skip to D6.1.  
Because of your health condition, in the past 30 days, how much difficulty did you have in:  
D5.5 Your day-to-day work/school?  None Mild Moderate Severe Extreme or 
cannot do  
 
____ 
20 
  
____ 
5 
 D5.6 Doing your most important work/school tasks well?  None Mild Moderate Severe Extreme or 
cannot do  
D5.7 Getting all of the work done that you need to do?  None Mild Moderate Severe Extreme or 
cannot do