Critical Support: Pre-Assessment Form
Name
*
Email
*
Phone
*
Age
Understanding and communicating
Concentrating on doing something for ten minutes?
None
Mild
Moderate
Severe
Extreme or cannot do
Remembering to do important things?
None
Mild
Moderate
Severe
Extreme or cannot do
Analyzing and finding solutions to problems in day-to-day life?
None
Mild
Moderate
Severe
Extreme or cannot do
Learning a new task, for example, learning how to get to a new place?
None
Mild
Moderate
Severe
Extreme or cannot do
Generally understanding what people say?
None
Mild
Moderate
Severe
Extreme or cannot do
Starting and maintaining a conversation?
None
Mild
Moderate
Severe
Extreme or cannot do
Getting around
Standing for long periods, such as 30 minutes?
None
Mild
Moderate
Severe
Extreme or cannot do
Standing up from sitting down?
None
Mild
Moderate
Severe
Extreme or cannot do
Moving around inside your home?
None
Mild
Moderate
Severe
Extreme or cannot do
Getting out of your home?
None
Mild
Moderate
Severe
Extreme or cannot do
Walking a long distance, such as a kilometer (or equivalent)?
None
Mild
Moderate
Severe
Extreme or cannot do
Self-care
Washing your whole body?
None
Mild
Moderate
Severe
Extreme or cannot do
Getting dressed?
None
Mild
Moderate
Severe
Extreme or cannot do
Eating?
None
Mild
Moderate
Severe
Extreme or cannot do
Staying by yourself for a few days?
None
Mild
Moderate
Severe
Extreme or cannot do
Getting along with people
Dealing with people you do not know?
None
Mild
Moderate
Severe
Extreme or cannot do
Maintaining a friendship?
None
Mild
Moderate
Severe
Extreme or cannot do
Getting along with people who are close to you?
None
Mild
Moderate
Severe
Extreme or cannot do
Making new friends?
None
Mild
Moderate
Severe
Extreme or cannot do
Sexual activities?
None
Mild
Moderate
Severe
Extreme or cannot do
Life activities—Household
Taking care of your household responsibilities?
None
Mild
Moderate
Severe
Extreme or cannot do
Doing most important household tasks well?
None
Mild
Moderate
Severe
Extreme or cannot do
Getting all of the household work done that you needed to do?
None
Mild
Moderate
Severe
Extreme or cannot do
Getting your household work done as quickly as needed?
None
Mild
Moderate
Severe
Extreme or cannot do
Life activities—School/Work
Your day-to-day work/school?
None
Mild
Moderate
Severe
Extreme or cannot do
Doing your most important work/school tasks well?
None
Mild
Moderate
Severe
Extreme or cannot do
Getting all of the work done that you need to do?
None
Mild
Moderate
Severe
Extreme or cannot do
Getting your work done as quickly as needed?
None
Mild
Moderate
Severe
Extreme or cannot do
Participation in society
How much of a problem did you have in joining in community activities (for example, festivities, religious, or other activities) in the same way as anyone else can?
None
Mild
Moderate
Severe
Extreme or cannot do
How much of a problem did you have because of barriers or hindrances around you?
None
Mild
Moderate
Severe
Extreme or cannot do
How much of a problem did you have living with dignity because of the attitudes and actions of others?
None
Mild
Moderate
Severe
Extreme or cannot do
How much time did you spend on your health condition or its consequences?
None
Mild
Moderate
Severe
Extreme or cannot do
How much have you been emotionally affected by your health condition?
None
Mild
Moderate
Severe
Extreme or cannot do
How much has your health been a drain on the financial resources of you or your family?
None
Mild
Moderate
Severe
Extreme or cannot do
How much of a problem did your family have because of your health problems?
None
Mild
Moderate
Severe
Extreme or cannot do
How much of a problem did you have in doing things by yourself for relaxation or pleasure?
None
Mild
Moderate
Severe
Extreme or cannot do
Δ
>