Опросник для оценки состояния здоровья ( HAQ )

Ф.И.О. ___________ Визит _________   Дата заполнения ______________

 

В этом разделе мы хотим выяснить, как Ваше заболевание сказывается на вашей способности выполнять повседневные действия. Вы можете прокомментировать свои ответы на обратной стороне этого листа.

Пожалуйста, отметьте крестиком тот ответ, который наиболее точно отражает Вашу способность выполнять повседневные действия ЗА ПРОШЕДШУЮ НЕДЕЛЮ:

	без всякого труда	с некото-рым трудом	с боль-шим трудом	не в состо-янии делать этого
Одевание и уход за собой Вы были в состоянии: - одеться, в том числе зашнуровать ботинки и застегнуть пуговицы? - Вымыть себе голову?
Вставание Вы были в состоянии: - Встать с обычного стула (без подлокотников)? -Лечь в кровать и встать с кровати?
Прием пищи Вы были в состоянии: -Нарезать мясо на куски? -Поднести ко рту полную чашку или стакан? -Вскрыть картонную упаковку молока или кефира?
Ходьба  Вы были в состоянии: - Ходить по ровной местности вне дома - Подняться по лестнице на 5 ступенек

Пожалуйста, отметьте, используете ли Вы обычно какие-либо из указанных

вспомогательных средств или приспособлений для выполнения перечисленных выше  действий (поставьте крестик):

		Палка		Приспособления для одевания (для застегивания пуговиц или молний, рожок для обуви с длинной ручкой, и т.п.)
		Ходунок		Специальная кухонная утварь (с толстыми ручками)
		Костыли		Специальный стул
	Инвалидная коляска			Другие (укажите какие)

 СПИСОК ЛИТЕРАТУРЫ

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