Dartmouth COOP Functional Assessment Charts Physical …

1 Dartmouth coop Functional Assessment ChartsPhysical FitnessDuring the past 2 weeks,What was the hardest Physical activity you could do for at least 2 minutes? coop Functional Assessment Charts 521475 Rev 08/19 Not to be scanned into EHR. Enter results directlhy into Epic Page 1 of 9 Copyright Trustees of Dartmouth College, coop Project, 200912345 Very heavy for example: Run, fast pace Carry a heavy load upstairs or uphill (25 pounds or 10 kilograms) Heavy for example: Jog, slow pace Climb stairs or a hill at moderate paceModerate for example: Walk, medium pace Carry a heavy load on level ground (25 pounds or 10 kilograms)Light for example: Walk, medium pace Carry light load on level groundVery light for example: Walk, slow pace Wash dishesDartmouth coop Functional Assessment ChartsFeelingsDuring the past 2 weeks,How much have you been bothered by emotional problems such as feeling anxious, depressed, irritable or downhearted and blue?

2 coop Functional Assessment Charts 521475 Rev 08/19 Not to be scanned into EHR. Enter results directlhy into Epic Page 2 of 9 Copyright Trustees of Dartmouth College, coop Project, 2009 Not at allSlightlyModeratelyQuite a bitExtremely12345 Dartmouth coop Functional Assessment ChartsDaily ActivitiesDuring the past 2 weeks, both inside and outside the house because of your Physical and emotional health? coop Functional Assessment Charts 521475 Rev 08/19 Not to be scanned into EHR. Enter results directlhy into Epic Page 3 of 9 Copyright Trustees of Dartmouth College, coop Project, 2009 Could not do12345 Dartmouth coop Functional Assessment ChartsSocial ActivitiesDuring the past 2 weeks,Has your Physical and emotional health limitedyour social activities with family, friends, neighbors or groups?

3 Not at allSlightlyModeratelyQuite a bitExtremely coop Functional Assessment Charts 521475 Rev 08/19 Not to be scanned into EHR. Enter results directlhy into Epic Page 4 of 9 Copyright Trustees of Dartmouth College, coop Project, 200912345 Dartmouth coop Functional Assessment ChartsPainDuring the past 2 weeks,How much bodily pain have you generally had?No painVery mild painMild painModerate painSevere painCOOP Functional Assessment Charts 521475 Rev 08/19 Not to be scanned into EHR. Enter results directlhy into Epic Page 5 of 9 Copyright Trustees of Dartmouth College, coop Project, 200912345 Dartmouth coop Functional Assessment ChartsChange In HealthHow would you rate your overall health now compared to 2 weeks ago?Much betterA little betterAbout the sameA little worseMuch worse12345 coop Functional Assessment Charts 521475 Rev 08/19 Not to be scanned into EHR.

4 Enter results directlhy into Epic Page 6 of 9 Copyright Trustees of Dartmouth College, coop Project, 2009 Dartmouth coop Functional Assessment ChartsOverall HealthDuring the past 2 weeks, how would you rate your health in general?ExcellentVery goodGoodFairPoor12345 coop Functional Assessment Charts 521475 Rev 08/19 Not to be scanned into EHR. Enter results directlhy into Epic Page 7 of 9 Copyright Trustees of Dartmouth College, coop Project, 2009 Dartmouth coop Functional Assessment ChartsSocial SupportDuring the past 2 weeks, was someone available to help you if you needed and wanted help? For example, if you: felt nervous, lonely, or blue got sick and had to stay in bed needed someone to talk to needed help with daily chores needed help just taking care of yourselfYes, as much as I wantedYes, quite a bitYes, someYes, a littleNo, not at allCOOP Functional Assessment Charts 521475 Rev 08/19 Not to be scanned into EHR.

5 Enter results directlhy into Epic Page 8 of 9 Copyright Trustees of Dartmouth College, coop Project, 200912345 Dartmouth coop Functional Assessment ChartsQuality of LifeHow have things been going for you during the past 2 weeks?Very well: could hardly be betterPretty goodGood and bad parts about equalPretty badVery bad: could hardly be worse coop Functional Assessment Charts 521475 Rev 08/19 Not to be scanned into EHR. Enter results directlhy into Epic Page 9 of 9 Copyright Trustees of Dartmouth College, coop Project, 200912345