Washington Group on Disability Statistics

Annex 1: Extended Questions for Core Functional Domains

Vision:

Do you have difficulty seeing and recognizing a person you know from 7 meters (20 feet) away?
Do you have difficulty seeing the print in a map, newspaper, or book?

Hearing:

Mobility:

Cognition:

Do you have difficulty remembering the names of people or places?
Do you have difficulty remembering appointments?
Do you have difficulty remembering how to get to familiar places?
Do you have difficulty remembering important tasks, like taking medications or paying bills?
Do you have difficulty concentrating on doing something for 10 minutes?
Do you have difficulty learning a new task, for example, learning how to get to a new place?
Do you have difficulty finding solutions to problems in day to day life?

Communication:

Self Care:

Do you have difficulty reaching up over your head?
Do you have difficulty reaching out as if to shake someone’s hand?
Do you have difficulty using your fingers to button a shirt or dress?
Do you have difficulty putting on socks or stocking?
Do you have difficulty tying your shoelaces?
Do you have difficulty combing your hair?
Do you have difficulty feeding yourself?