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Patient Activity Scale-II (PAS-II)

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Patient Activity Scale-II (PAS-II)

We are interested in learning how your illness


affects your ability to function in daily life. Place
an X in the box which best describes your usual
abilities OVER THE PAST WEEK:
Are you able to:

Without Any
Difficulty
(0)

With Some
Difficulty
(1)

With Much
Difficulty
(2)

Unable
To Do
(3)

Stand up from a straight chair?


Walk outdoors on flat ground?
Get on/off toilet?
Reach and get down a 5 pound object (such as a bag
of sugar) from just above your head?
Open car doors?
Do outside work (such as yard work)?
Wait in a line for 15 minutes?
Lift heavy objects?
Move heavy objects?
Go up two or more flights of stairs?

We are also interested in learning whether or not you are affected by pain because of your illness.
How much pain have you had because of your illness in the past week? Place an X in the box that best describes the severity of
your pain on a scale of 0-10.

10

NO PAIN

SEVERE PAIN

Considering ALL THE WAYS THAT YOUR ILLNESS AFFECTS YOU, RATE HOW YOU ARE DOING on the following scale. Place an X
in the box below that best describes how you are doing on a scale of 0-10.
VERY
WELL

10

VERY
POOR

Draft

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