• In the past 2 weeks, how difficult was it to use your hand that was most affected by your stroke to tie a shoe lace?
• In the past 2 weeks, how difficult was it to use your hand that was most affected by your stroke to pick up a dime?
• During the past 4 weeks, how much of the time have you been limited in your work (paid, voluntary or other)?
• During the past 4 weeks, how much of the time have you been limited in your social activities?
• During the past 4 weeks, how much of the time have you been limited in your quiet recreation (crafts, reading)?
• During the past 4 weeks, how much of the time have you been limited in your active reacreation (sports, outings, travel)?
• During the past 4 weeks, how much of the time have you been limited in your role as a family member and/or friend?
• During the past 4 weeks, how much of the time have you been limited in your participation in spiritual or religious activities?
• During the past 4 weeks, how much of the time have you been limited in your ability to control your life as you wish?
• During the past 4 weeks, how much of the time have you been limited in your ability to help others?
• On a scale of 0 to 100, with 100 representing full recovery and 0 representing no recovery, how much have you recovered from your stroke?
• How many episodes?
• How many days were missed?
• Date of visit
• Name of hospital, city, state
• Level of consciousness
• LOC questions
• LOC commands
• Best gaze
• Visual