FPT Dash Questionaire

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FPT Dash Questionaire

Please rate your ability to do the following activities in the last week by circling the number blow the appropriate response.

NO DIFFICULTY MILD DIFFICULTY MODERATE DIFFICULTY SEVERE DIFFICULTY UNABLE
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5

EXTREME
NOT LIMITED AT ALL SLIGHTLY LIMITED MODERATELY LIMITED VERY LIMITED UNABLE
1 2 3 4 5

Please rate the severity of the following symptoms in the last week. (circle number)
NONE MILD MODERATE SEVERE EXTREME
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5