Teil 1: Körperpflege / Aktivitäten des täglichen Lebens
Wie schwierig war Folgendes in den letzten 2 Wochen
integer
Wie schwierig war Folgendes in den letzten 2 Wochen
integer
Wie schwierig war Folgendes in den letzten 2 Wochen
integer
Wie schwierig war Folgendes in den letzten 2 Wochen
integer
Wie schwierig war Folgendes in den letzten 2 Wochen
integer
Wie schwierig war Folgendes in den letzten 2 Wochen
integer
4. toileting activities: difficulty
integer
4. toileting activities: level of assistance
integer
5. changing diapers/underwear: difficulty
integer
5. changing diapers/underwear: level of assistance
integer
6. putting on/taking off upper body clothing: difficulty
integer
6. putting on/taking off upper body clothing: level of assistance
integer
7. putting on/taking off lower body clothing: difficulty
integer
7. putting on/taking off lower body clothing: level of assistance
integer
8. putting on/wearing footwear: difficulty
integer
8. putting on/wearing footwear: level of assistance
integer
9. hair care: difficulty
integer
9. hair care: level of assistance
integer
1A. other personal care activity
text
1A. other personal care activity: difficulty
integer
1A. other personal care activity: level of assistance
integer
1B. other personal care activity
text
1B. other personal care activity: difficulty
integer
1B. other personal care activity: level of assistance
integer
Part 1: difficulty score
text
Part 1: level of assistance score
text
Part 1: total score
text
2. Positioning, Transferring & Mobility
10. getting in and out of bed: difficulty
integer
10. getting in and out of bed: level of assistance
integer
11. transferring into /out of a wheelchair/chair: difficulty
integer
11. transferring into /out of a wheelchair/chair: level of assistance
integer
12. sitting in a wheelchair/chair: difficulty
integer
12. sitting in a wheelchair/chair: level of assistance
integer
13. standing for exercise/transfers: difficulty
integer
13. standing for exercise/transfers: level of assistance
integer
14. moving about in the home: difficulty
integer
14. moving about in the home: level of assistance
integer
15. moving about outdoors: difficulty
integer
15. moving about outdoors: level of assistance
integer
16. getting in and out of a motor vehicle: difficulty
integer
16. getting in and out of a motor vehicle: level of assistance
integer
17. visiting public places: difficulty
integer
17. visiting public places: level of assistance
integer
2A. other activity
text
2A. other activity: difficulty
integer
2A. other activity: level of assistance
integer
2B. other activity
text
2B. other activity: difficulty
integer
2B. other activity: level of assistance
integer
Part 2: difficulty score
text
Part 2: level of assistance score
text
Part 2: total score
text
3. Comfort & Emotions
18. while eating/drinking or being fed: frequency
integer
18. while eating/drinking or being fed: intensity
integer
19. during toileting: frequency
integer
19. during toileting: intensity
integer
20. while dressing/undressing: frequency
integer
20. while dressing/undressing: intensity
integer
21. during transfers or position changes: frequency
integer
21. during transfers or position changes: intensity
integer
22. while seated: frequency
integer
22. while seated: intensity
integer
23. while lying down in bed: frequency
integer
23. while lying down in bed: intensity
integer
24. that disturbed your child’s sleep: frequency
integer
24. that disturbed your child’s sleep: intensity
integer
3A. during other activity
text
3A. during other activity: frequency
integer
3A. during other activity: intensity
integer
3B. during other activity
text
3B. during other activity: frequency
integer
3B. during other activity: intensity
integer
25. agitated, upset, or angry: frequency
integer
25. agitated, upset, or angry: intensity
integer
26. unhappy or sad: frequency
integer
26. unhappy or sad: intensity
integer
Part 3: frequency score
text
Part 3: intensity score
text
Part 3: total score
text
4. Communication & Social Interaction
27. understanding you: difficulty
integer
28. being understood by you: difficulty
integer
29. communicating with strangers: difficulty
integer
30. playing alone: difficulty
integer
31. playing with others: difficulty
integer
32. attending school/child care: difficulty
integer
33. participating in recreational activities: difficulty
integer
4A. other social activity
text
4A. other social activity: difficulty
integer
4B. other social activity
text
4B. other social activity: difficulty
integer
Part 4: total score
text
5. Health
34. Visits of doctor/hospital: frequency
integer
35. Overall health
integer
36. List of medications
text
Part 5: total score
text
6. Overall Quality of Life
7. Importance of items to your child's quality of life
1. Eating / drinking or being fed
integer
2. Maintaining oral hygiene
integer
3. Bathing / washing
integer
4. Toileting activities / hygiene
integer
5. Changing diapers / underwear
integer
6. Putting on/taking off upper clothing
integer
7. Putting on/taking off lower clothing
integer
8. Putting on / wearing footwear
integer
9. Hair care / grooming
integer
10. Getting in and out of bed
integer
11. Transferring into / out of a wheel chair / chair
integer
12. Sitting in a wheelchair / chair
integer
13. Standing for exercise / transfers
integer
14. Moving about indoors
integer
15. Moving about outdoors
integer
16. Getting in / out of a motor vehicle
integer
17. Visiting public places
integer
18. Comfort while feeding
integer
19. Comfort during toileting activities
integer
20. Comfort while dressing /undressing
integer
21. Comfort during transfers or position changes
integer
22. Comfort while sitting
integer
23. Comfort while lying down
integer
24. Comfort while sleeping
integer
25. Emotional state or behavior
integer
26. Happiness
integer
27. Able to understand you
integer
28. Able to be understood by you
integer
29. Able to communicate with others
integer
30. Able to play alone
integer
31. Able to play with others
integer
32. Able to attend school / child care
integer
33. Able to participate in recreational activities
integer
34. Minimizing doctor visits and hospitalization
integer
35. Overall health
integer
36. Minimizing number of medications
integer
Part 7: total score
text
8. Facts about your child
Sex
text
Date of birth
date
Highest school grade completed
text
If ungraded, how many years attended?
text
9. Facts about you
Sex
text
Date of birth
date
Current work status: Not working due to child’s health
boolean
Current work status: Not working for other reasons
boolean
Current work status: Looking for work outside the home
boolean
Current work status: Working full or part time
boolean
Current work status: Full time homemaker
boolean
Relationship to child: Biological Parent
boolean
Relationship to child: Step Parent
boolean
Relationship to child: Foster Parent
boolean
Relationship to child: Adoptive Parent
boolean
Relationship to child: Guardian
boolean
Relationship to child: Professional caregiver
boolean
Relationship to child: Other
boolean
Relationship to child: Other (please explain)
text
Care giving (days per week)
integer
Highest level of school completed
text
CPChild result