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OACIS: Resources - Surveys

**NEW** Johns Hopkins Highest Level of Mobility scale

The Johns Hopkins Highest Level of Mobility (JH-HLM) scale is created to standardize the measurement and reporting of patient mobility in the hospital. The JH-HLM is currently being validated.  Anyone wishing to use this scale should submit a user request form.

**NEW** Survey Of Barriers to Early Mobility 

A novel survey instrument to identify important barriers to mobilizing medical inpatients. Results from this paper can assist with the implementation of quality improvement projects for increasing early hospital-based patient mobility.
Quality of Life


The Euro-QOL Group created the EQ-5D instrument as a simple indicator of quality of life that can be used internationally. EQ-5D measures physical, mental, and social well-being.  The EQ-5D incorporates a visual analog scale (VAS that allows the analyst to quantify health status on a measuring scale and the 5 domains of the EQ-5D can be converted to a utility score for health economic analyses.

Short Form 36 (SF36), version 2

The SF-36 Health Survey is a quality of life assessment tool. It includes 36 questions that are divided into 8 domains (Physical Functioning, Physical Role, Bodily Pain, General Health, Vitality, Social Functioning, Emotional Role, and Mental Health).

Mental Health

Hospital Anxiety and Depression Scale (HAD)

The HAD is used to identify whether participants are experiencing symptoms of anxiety and/or depression after their hospital stay. Moreover, the HAD is designed to detect anxiety and depression as separate disorders, rather than consider them as one illness.

Impact of Event Scale- Revised (IES-R)

Post-Traumatic Stress Disorder (PTSD) encompasses 4 major types of symptoms, and the IES-R  gauges each of these areas:
  • re-experiencing symptoms
  • avoidance symptoms (evading activities or other cues that remind the participant of the trauma);
  • numbing symptoms (i.e., loss of emotions);
  • arousal symptoms (increased sense of being on guard, often coupled with inability to sleep

Cognitive Function

Telephone Interview of Cognitive Status-Modified (TICS-M)

This instrument is designed to test for cognitive difficulties in an individual. This survey assesses performance in the following categories: orientation, registration, attention, comprehension, repetition, and delayed recall.

Mini-Mental State Examination -Telephone Version (MMSE)

This is an adaptation of the MMSE for telephone administration and includes the five groups of questions: orientation, registration, attention, recall, and language.

Controlled Oral Word Association Test

 This is a short, timed test that evaluates a patient’s executive function. Participants are read a letter, and they are told to come up with as many words as possible that begin with the given letter.

Digit Span test: A validated test measuring short-term memory and attention. The subjects are asked to repeat series of numbers read to them by the examiner in forward or backward order.

Trail Making Test A + B: A validated test measuring processing speed and executive function. This is a timed test where the subject connects a series of numbered or alternating numbered-lettered circles as quickly as possible.

Physical Activities

Functional Performance Inventory (FPI) – Short Form

This survey is a short version of the FPI. The FPI collects information about a person’s activities in and out of the house. In addition, the survey assesses how much a person’s health might limit their social interactions.

Activities of Daily Living

ADL questionnaire includes the following tasks: bathing, dressing, toileting, transferring from bed to chair, continence and feeding. 

Instrumental Activities of Daily Living

IADL questionnaire includes the following tasks: using the telephone, shopping, food preparation, housekeeping, laundry, transportation, administering medications, and handling personal finances. 

Dementia Screening

AD8-Dementia Screening Interview

The AD-8 is a screening tool for early dementia. The assessment only uses 8 questions, and it evaluates any cognitive changes that might have occurred in the past several years using both participant and proxy report.

Modified Blessed Dementia Rating Scale (MBDRS)

The Modified Blessed Dementia Rating Scale (MBDRS) is an assessment tool used for measuring cognitive impairment using a proxy assessment. The goal of this scale is to assess the patient’s competence in performing personal activities (e.g. performing household activities and handling small sums of money). 

Various Other Surveys

Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale (V4)

FACIT measures fatigue in responders and how fatigue affects their activities. This instrument can be adapted to specific diseases/disabilities (i.e. how the disease/disability has affected an individual’s energy levels). This version is the most basic and universal aspect of the FACIT measurement system.

Sydney Swallowing Questionnaire

The purpose of this form is to assess the study participant’s ability to swallow. This instrument measures swallowing problems using a visual analogue scale ranging from no problems, on the left, to extreme problems, on the right. 

Social Support Questionnaire-Short Form

This instrument asks about the people in the patient’s environment who provide the patient with help or support. In addition, the patient is asked of their satisfaction with the support that he/she receives.

Hearing Handicap Inventory for Adults – Screening (HHIAS)

A 10-item questionnaire assessing for hearing difficulty in various situations.

Richards-Campbell Sleep Questionnaire: A 5-question instrument using a visual-analog scale to measure perceived sleep quality in ICU patients. The survey has been validated against polysomnography in the ICU patient population and addresses perceived sleep depth, sleep latency, awakenings, ability to return to sleep, and overall sleep quality.

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