4 Functional Status

WHI

Form 90 – Functional Status

Ver. 2 (Draft)
OMB # 0925-0414

Public reporting for this collection of information is estimated to average 10 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the information needed and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it is displays a currently valid OMB control number. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,
Bethesda, MD 20892-7974, ATTN: PRA (0925-0414). Do not return the completed form to this
address.

1. Date of exam:

-

-

Exp: XX/XXXX

- Affix label hereClinical Center/ID: __ __

__ __ - ___ ___ ___ - __

First Name ________________________M.I.______
Last Name _________________________________

(M/D/Y)

2. Performed by:

____________________________

3. Contact type:

4 Home Visit
8 Other
4. Visit type:
X Non-Routine

4
Performance Measures
5. Grip strength:
5.1. Side tested:

1 Right
2 Left
3 Attempted, unable to complete on either side
8 Refused
9 Not attempted for safety or health reasons
5.2.

Dominance of hand used:

1 Dominant
2 Non-dominant
5.3.

Measurement #1:

kg

5.4.

Measurement #2:

kg

6. Balance test
Test completed or
partially completed
6.1. Side-by-side
6.2. Semi-tandem
6.3. Tandem stand
6.4. One-leg stand

1
1
1
1

.

seconds

.

seconds

.

seconds

.

seconds

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Attempted,
unable to
complete

Refused

Not
attempted

2
2
2
2

8
8
8
8

9
9
9
9

Pg. 1 of 4

WHI

Form 90 – Functional Status

Ver. 2 (Draft)
OMB # 0925-0414

Exp: XX/XXXX

K_______ V_______

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11/12/09

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WHI

Form 90 – Functional Status

Ver. 2 (Draft)
OMB # 0925-0414

Exp: XX/XXXX

7. Timed walk

1 Test completed or partially completed
2 Attempted, unable to complete
8 Refused
9 Not attempted for safety or health reasons

7.1. Time:

.

seconds

7.2. Time:

.

seconds

7.3. Assistive device used?

0 No

1 Yes

8. Single chair stand:

1 Test completed, arises without using her arms
2 Test completed, arises using her arms
3 Arises, unable to rise from chair
8 Refused
9 Not attempted for safety or health reasons

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Repeated chair stands in 15 seconds:
8.1.

stands

8.2.

stands

Pg. 3 of 4

WHI

Form 90 – Functional Status

Ver. 2 (Draft)
OMB # 0925-0414

Spanish translation not needed; interviewer administered form
Instructions to WHI Staff under development

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11/12/09

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Exp: XX/XXXX