OARS Multidimensional Functional Assessment Questionnaire

              Patient


              Please complete the following information:

                First Name: Last Name:
                Patient
                City: State: Country:
                What is your city, state and country of primary residence?

              PHYSICAL ACITIVITIES OF DAILY LIVING

              Please Select:
              Do you eat...
              Do you dress and undress yourself...
              Do you take care of your own appearance
              (by combing your hair, shaivng, etc.)...
              Do you get aournd your house, apartment, or room...
              Do you get into or out of bed...
              Do you bathe-that is, take a bath, shower, or sponge bath...
              Do you ever have trouble getting to the bathroom on time?
              About how often do you wet or soil yourself during the day or night?

              INSTRUMENTAL ACTIVITIES OF DAILY LIVING

              Please Select:
              Can you use the telephone...
              Can you get to places out of walking distance...                    
              Can you go shopping for groceries...
              Can you prepare your own meals...
              Can you do housework...
              Can you do your own handyman work...
              Can you do your own laundry...
              Do you currently take or use any medications?
              If YES Do you take medication...
              If NO could you take medication...
              Can you manage your own money...

              Please review your answers. Are you ready to submit your survey?