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Home
Short EMIR Questionnaire
Short EMIR Questionnaire
Answer all questions.
Over the past four weeks:
Mandatory fields
1
Have you been physically able to drive a car or use public transport?
Every day
Nearly every day
Sometimes
Rarely
Never
2
Do you remain sitting or lying down most of the day or all day?
Every day
Nearly every day
Sometimes
Rarely
Never
3
Have you had difficulty with any strenuous activity such as running, lifting heavy objects or playing sports?
Every day
Nearly every day
Sometimes
Rarely
Never
4
Have you had difficulty walking several hundred metres or going up several flights of stairs?
Every day
Nearly every day
Sometimes
Rarely
Never
5
To walk have you needed help from someone or a cane, crutches or other equipment?
Every day
Nearly every day
Sometimes
Rarely
Never
6
Have you been able to write easily with a pen or pencil?
Every day
Nearly every day
Sometimes
Rarely
Never
7
Have you been able to button clothes easily?
Every day
Nearly every day
Sometimes
Rarely
Never
8
Have you been able to turn a key in a lock easily?
Every day
Nearly every day
Sometimes
Rarely
Never
9
Have you been able to comb or brush your hair easily?
Every day
Nearly every day
Sometimes
Rarely
Never
10
Have you been able to easily reach any shelves up high above your head?
Every day
Nearly every day
Sometimes
Rarely
Never
11
Have you had need of someone's help to get dressed?
Every day
Nearly every day
Sometimes
Rarely
Never
12
Have you had need of someone's help to get in or out of bed?
Every day
Nearly every day
Sometimes
Rarely
Never
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