CR Health Assessment I

CR Health Assessment I - OFFICE USE ONLY H EALTH ASSESSMENT...

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OFFICE USE ONLY Project ID: __ __ __ __ __ Date: __ __/__ __/ 20__ __ Patient ID: __ __ __ __ Code: __ __ File: ODM The forms in this booklet ask you detailed questions about your health. Please read the instructions for each set of questions before giving your answers. If you have any questions, please ask for help. Roland Morris Questionnaire ± 1. I stay home most of the time because of my back. ± 2. I change position frequently to try and get my back comfortable. ± 3. I walk more slowly than usual because of my back. ± 4. Because of my back I am not doing any of the jobs that I usually do around the house. ± 5. Because of my back, I use a handrail to get upstairs. ± 6. Because of my back I lie down to rest more often. ± 7. Because of my back, I have to hold on to something to get out of an easy chair. ± 8. Because of my back, I try to get other people to do things for me. ± 9. I get dressed more slowly than usual because of my back. ± 10. I only stand up for short periods of time because of my back. ± 11. Because of my back, I try not to bend or kneel down.
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CR Health Assessment I - OFFICE USE ONLY H EALTH ASSESSMENT...

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