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Total # of Questions: 20

Neuro-Qol pediatric item scale - upper extremity - version 1.0 [NeuroQol.Peds] [68135-3]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

In the past 7 days I was able to use my fingers to point to something. [68294-8]

In the past 7 days I was able to take off my socks. [68295-5]

In the past 7 days I was able to put on and fasten my pants by myself. [68296-3]

In the past 7 days I was able to button and unbutton my shirt. [68297-1]

In the past 7 days I was able to use a spoon to bring food up to my mouth. [68298-9]

In the past 7 days I was able to wipe myself thoroughly after using the toilet. [68299-7]

In the past 7 days I was able to pull my pants back up after using the toilet. [68300-3]

In the past 7 days I was able to hold a plate full of food. [68301-1]

In the past 7 days I was able to cut a piece of paper in half with scissors. [68302-9]

In the past 7 days I was able to take a shower by myself. [68303-7]

In the past 7 days I was able to take a bath by myself. [68304-5]

In the past 7 days I was able to make a phone call using a touch tone key-pad. [68305-2]

In the past 7 days I was able to get out of bed by myself. [68306-0]

In the past 7 days I was able to put on my shoes by myself. [68307-8]

In the past 7 days I was able to open a jar by myself. [68308-6]

In the past 7 days I was able to put toothpaste on my toothbrush by myself. [68309-4]

In the past 7 days I was able to brush my teeth by myself. [68310-2]

In the past 7 days I was able to dry my back with a towel. [68311-0]

In the past 7 days I was able to put on my clothes by myself. [68312-8]

In the past 7 days I was able to zip up my clothes. [68313-6]

PLEASE WAIT