CDEs
Forms
In the past 7 days, when my child was in pain he/she lay down.
In the past 7 days I had to read something several times to understand it
In the past 7 days my thinking was slow
In the past 7 days I could stand up by myself.
When I stop what I'm doing to have a cigarette it feels like 'my time'.
Are you able to brush your teeth?
Are you able to wash and dry your body?
Are you able to shampoo your hair?
In the past 30 days How interested have you been in sexual activity?
I was too tired to enjoy the things I like to do.
I had trouble starting things because I was too tired.
In the past 7 days I felt like a failure
Thinking about my life, I have a reason for living.
Are you able to get in and out of a car?
In the past 7 days I could open the rings in school binders.
Considering your shortness of breath <u>over the past 7 days</u>, rate the amount of difficulty you had when doing the following activities: Washing dishes
Considering your shortness of breath <u>over the past 7 days</u>, rate the amount of difficulty you had when doing the following activities: Lifting something weighing 10-20 lbs (about 4.5-9 kg, like a large bag of groceries)
In the past 7 days I am satisfied with my ability to run errands
In the past 7 days I am satisfied with my ability to do household chores/tasks
In the past 7 days My child could pull a shirt on over his/her head without help.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31