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User details
First name
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Username
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E-mail address
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Organisation
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Gender identity
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female
male
non-binary/third gender
not listed
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Short Set of Washington Group Questions
The next questions ask about difficulties you may have doing certain activities because of a health problem
Do you have difficulty seeing, even if wearing glasses?
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- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Do you have difficulty hearing, even if using a hearing aid?
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- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Do you have difficulty walking or climbing steps?
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- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Do you have difficulty remembering or concentrating?
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- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Do you have difficulty (with self-care such as) washing all over or dressing?
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- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Using your usual (customary) language, do you have difficulty communicating, for example understanding or being understood?
*
- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
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