Welcome to the University of Florida ICF Activity Measure System, presented by the College of Public Health and Health Professions, Department of Occupational Therapy. Please provide us with the following information about yourself. This information will be kept strictly confidential and is used for demographic analysis only. Once completed, click the 'Continue' button.

Please select the side that the disease/injury affects?		Preferred/dominant hand Non-preferred/non-dominant hand
		Not Applicable(e.g., back pain, leg injury/amuptation, hip/knee replacement)
ICD-9/10 code for primary diseases/impairments:
PLEASE FILL IN THE FOLLOWING SECTION ONLY IF YOU DO NOT HAVE AN ICD-9/10 CODE
Neurological Disease		Select Not Applicable Stroke/Cerebrovascular accident (CVA) Traumatic Brain Injury Brain Tumor Dementia Multiple Sclerosis Parkinson's Disease Peripheral Nerve Disorder/Polyneuropathy Epilepsy/Seizure Disorder Guillain-Barre' Syndrome Spinal Cord Injury with Complete Quadriplegia Spinal Cord Injury with Incomplete Quadriplegia Spinal Cord Injury with Complete Paraplegia Spinal Cord Injury with Incomplete Paraplegia
Musculoskeletal		Select Not Applicable Amputation of arms above the elbows Amputation of arms below the elbows Amputation of legs above the knees Amputation of legs below the knees Amputation of one arm above the elbow Amputation of one arm below the elbow Amputation of one leg above the knee Amputation of one leg below the knee Neck Pain Upper Back Pain Lower Back Pain Arm Fracture Hand/Wrist Fracture Hip Fracture Upper Leg Fracture Lower Leg Fracture Replacement of one shoulder joint Replacement of both shoulder joints Replacement of one hip joint Replacement of both hip joints Replacement of one knee joint Replacement of both knee joint
Arthritis		Select Not Applicable Rheumatoid Arthrtis in the shoulder joints Rheumatoid Arthritis in the elbow joints Rheumatoid Arthritis in the wrist joints Rheumatoid Arthritis in the hands Rheumatoid Arthritis in the hip joints Rheumatoid Arthritis in the knee joints Rheumatoid Arthritis in the Ankle Rheumatoid Arthritis in the feet Osteoarthritis in the shoulder joint Osteoarthritis in the elbow joint Osteoarthritis in the wrist joints Osteoarthritis in the hand Osteoarthritis in the hip joint Osteoarthritis in the knee joint Osteoarthritis in the ankle Osteoarthritis in the foot
Cardiovascular disease		Select Not Applicable Heart trouble (CHF, angina) High blood pressure Circulation trouble in arms or legs, peripheral vascular disease including aneurysm
Pulmonary/respiratory disorders		Select Not Applicable Asthma Emphysema or Chronic Bronchitis Chronic Obstructive Pulmonary Disease
Skin disorders		Select Not Applicable Burns Pressure sores/leg ulcers
Other Disease/Impairments		Select Not Applicable Corrected vision problems Not corrected vision problems Corrected hearing problems Not corrected hearing problems Cancer Anemia Diabetes Thyroid disorders Liver diseases Stomach or Intestinal Ulcers Kidney Diseases Cerebral Palsy Spina Bifida Affective Disorder or Depression
Other Not listed above
Movement/Body Position Difficulties (check all that apply)		Difficulty maintaining a position (for example; lying, sitting, standing), changing positions (for example; lying to sitting, rolling over in bed), or transferring (for example; getting in/out of a bathtub, moving from bed to wheelchair).
		Difficulty carrying, lifting, pulling or pushing.
		Difficulty using hands (for example; picking up coins, opening a jar).
		Difficulty walking or climbing (for example; walking a block, climbing stairs).
		Difficulty using a manual or motorized wheelchair/scooter.
		Difficulty with self-care activities (for example; bathing, dressing, toileting).
Do you:		Walk Use a wheelchair Both If you use a wheelchair, do you use a: Manual Wheelchair Electric Wheelchair Both Manual and Electric
Gender:		Male Female
Age:
Living Situation		Living in the Community Hospital/Nursing Home/Assisted Living Facility
		Other:
Highest Level of Schooling		Never attended Elementary Middle/Junior High High School		College Graduate Technical
		Other:
Race/Ethnic:		African American Hispanic American American Indian		Alaskan Native White non-hispanic Asian/Pacific Islander
		Other:

Do you have a spinal cord injury?		Yes No
Can you walk without assistance (Without a cane or walker)?		Yes No
Can you perform basic activities such as bathing, dressing and grooming without assistance?		Yes No
Can you perform more complex activities such as preparing a simple meal, doing household chores, managing money, shopping or traveling locally without assistance?		Yes No
Can you participate in work and/or leisure activities without assistance?		Yes No

ICF Activity Measure

Demo

Demographics