Health Assessment Questionnaire (HAQ-DI)©

Assessment

Please review the questions below and select which best describes your abilities OVER THE PAST WEEK:

Dressing & Grooming

Without ANY Difficulty

With SOME Difficulty

With MUCH Difficulty

UNABLE to do

Are you able to:

Dress yourself, including tying shoelaces and doing buttons?

Shampoo your hair?
Arising

Without ANY Difficulty

With SOME Difficulty

With MUCH Difficulty

UNABLE to do

Are you able to:

Stand up from an armless chair?

Get in and out of bed?
Eating

Without ANY Difficulty

With SOME Difficulty

With MUCH Difficulty

UNABLE to do

Are you able to:

Cut up your own meat or vegetables?

Lift a full cup or glass to your mouth?

Open a new carton of milk (or soap powder)?
Walking

Without ANY Difficulty

With SOME Difficulty

With MUCH Difficulty

UNABLE to do

Are you able to:

Walk outdoors on flat ground?

Climb up five steps?
Aids & Devices

Please check any AIDS OR DEVICES that you use more than 50% of the time for any of the above activities:

Devices used for Dressing (button hook, zipper pull, etc.)

Built up or special utensils

Special or built up chair

Cane or Walker

Crutches

Wheelchair

Please check any categories for which you need HELP FROM ANOTHER PERSON more than 50% of the time:

Dressing & Grooming

Arising

Eating

Walking

Hygiene

Without ANY Difficulty

With SOME Difficulty

With MUCH Difficulty

UNABLE to do

Are you able to:

Wash and dry your entire body?

Get up off the floor?

Get on and off the toilet?
Reach

Without ANY Difficulty

With SOME Difficulty

With MUCH Difficulty

UNABLE to do

Are you able to:

Reach and get down a 5 lb object (e.g. a bag of potatoes) from just above your head?

Bend down to pick up clothing off the floor?
Grip

Without ANY Difficulty

With SOME Difficulty

With MUCH Difficulty

UNABLE to do

Are you able to:

Open car doors?

Open jars which have been previously opened?

Turn taps on and off?
Activities

Without ANY Difficulty

With SOME Difficulty

With MUCH Difficulty

UNABLE to do

Are you able to:

Run errands and shop?

Get in and out of a car?

Do chores such as vacuuming, housework or light gardening?
Aids & Devices

Please check any AIDS OR DEVICES that you use more than 50% of the time for any of the above activities:

Raised toilet seat (H)

Bath rail (H)

Bath seat (H)

Long-handled appliances for reach (R)

Jar opener (for jars previously opened) (G)

Please check any categories for which you need HELP FROM ANOTHER PERSON more than 50% of the time:

Hygiene

Gripping and opening things

Reach

Errands and housework

Your Pain & Overall Wellness

Your Pain
How much pain have you had IN THE PAST WEEK?
On a scale of 0 to 100, please record the number

/100

Global Assessment
How has your health been IN THE PAST WEEK specifically related to your arthritis?
On a scale of 0 to 100, please record the number

/100


How long do your joints feel stiff when you wake up in the morning?

Hours:
Minutes:
Scoring

HAQ Score

Export

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Personal Details

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