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WHODAS Form

Printed form – If you prefer, you can print this form, fill it out and deliver it to the office.

"*" indicates required fields

World Health Organization Disability Assessment Schedule


This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities.
For each question, please select only one response.
Name*
MM slash DD slash YYYY

In the past 30 days, how much difficulty did you have in:

H1 - Overall, in the past 30 days, how many days were these difficulties present?
Record number of days
H2- In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
Record number of days
H3 - In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?
Record number of days
This field is for validation purposes and should be left unchanged.