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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?
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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?
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During the past 4 weeks, how much of the time have you been limited in your work (paid, voluntary or other)?
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During the past 4 weeks, how much of the time have you been limited in your social activities?
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During the past 4 weeks, how much of the time have you been limited in your quiet recreation (crafts, reading)?
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During the past 4 weeks, how much of the time have you been limited in your active reacreation (sports, outings, travel)?
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During the past 4 weeks, how much of the time have you been limited in your role as a family member and/or friend?
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During the past 4 weeks, how much of the time have you been limited in your participation in spiritual or religious activities?
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During the past 4 weeks, how much of the time have you been limited in your ability to control your life as you wish?
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During the past 4 weeks, how much of the time have you been limited in your ability to help others?
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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?
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How many episodes?
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How many days were missed?
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Date of visit
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Name of hospital, city, state
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Level of consciousness
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LOC questions
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LOC commands
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Best gaze
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Visual