1.Grooming Tasks: Rate your quality of life for the following tasks

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

Brushing teeth (electric toothbrush)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

Brushing teeth (manual toothbrush)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

Shaving (electric)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

Shaving (manual rasor)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

Washing

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

Placement of in-ear hearing aids

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

coming hair

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

2.Dressing Tasks: Rate your quality of life for the following tasks

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

underwear (cloth)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

underwear (disposable)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

bra

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

trousers

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

t-shirts

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

button shirt

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

arm placement in button up shirt

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

button cuff

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

pullover shirt

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

arm placement in pullover shirt

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

belt placement

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

shoes (lace up)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

shoes (slip on)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

outer jacket

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

socks

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

skirt

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

3.BathroomTasks: Rate your quality of life for the following tasks

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

urination

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

bowel movement (normal)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

bowel movement (constipated)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

hygiene (general)

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

4.Eating Tasks: Rate your quality of life for the following tasks

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

cutting food

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

use of fork

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

use of spoon

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

use of knife

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

use of standard utensils

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

use of over-sized utensils

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

5.Writing Tasks: Rate your quality of life for the following tasks

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

handwriting

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

using standard pen

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

using over-sized pen

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

using computer

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

using i-pad

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

using cell phone

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

6.Gastrointestinal tasks: Rate your quality of life for the following tasks

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

cough

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

food debris

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

swallowing

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

speech

1 = no difficulty

2 = mild difficulty

3 = moderate difficulty

4 = moderate severe difficulty

5 = most difficult

7.Use of Aids-Please answer by checking the appropriate lines.
Yes - I currently use
No - I do not use

Yes

No

over-sized toothbrush

Yes

No

electric razor

Yes

No

standard razor

Yes

No

over-sized razor

Yes

No

standard pen

Yes

No

over-sized pen

Yes

No

zipper aid

Yes

No

long shoe horn

Yes

No

bottle opener

Yes

No

button hook

Yes

No

shoe/sock aid

Yes

No

cane

Yes

No

walker

Yes

No

walking sticks

Yes

No

wheel chair

Yes

No

bathroom grab bars

Yes

No

shower bench

Yes

No

door knob gripper

Yes

No

door knob extension

Yes

No

nail clipper over-sized

Yes

No

dressing aid stick

Yes

No

reacher grab tool

Yes

No

easy key holder

Yes

No

zipper lubricant

Yes

No

8.Please select whether you think the following aids are helpful (yes/no)

Yes

No

over-sized toothbrush

Yes

No

electric razor

Yes

No

standard razor

Yes

No

over-sized razor

Yes

No

standard pen

Yes

No

over-sized pen

Yes

No

zipper aid

Yes

No

long shoe horn

Yes

No

bottle opener

Yes

No

button hook

Yes

No

shoe/sock aid

Yes

No

cane

Yes

No

walker

Yes

No

walking sticks

Yes

No

wheel chair

Yes

No

bathroom grab bars

Yes

No

shower bench

Yes

No

door knob gripper

Yes

No

door knob extension

Yes

No

nail clipper over-sized

Yes

No

dressing aid stick

Yes

No

reacher grab tool

Yes

No

easy key holder

Yes

No

zipper lubricant

Yes

No