Adult WHODAS Intake

Thank you for choosing Northland Counseling Center! Please fill out the form below. Please remember to fill out the additional forms: Adult Registration Form, Adult Health Questionnaire, GAIN-SS, PHQ-9 & GAD 7. Thank you.

WHODAS Intake

Date
MM slash DD slash YYYY
Name
First Last
This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questoins, thinking about how much difficult you had doing the following activities. For each questions, please check only one response.
Standing for long periods such as 30 minutes
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
Taking care of your household responsibilities?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
Learning a new task, for example, learning how to get to a new place?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
How much of a problem did you have joining in community activities (For example, festivities, religious or other activities) in the same way as anyone else can?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
How much have you been emotionally affected by your health problems?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
Concentrating on doing something for ten minutes?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
Walking a long distance such as mile (or equivalent)?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
Washing your whole body?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
Getting Dressed?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
Dealing with people you do not know?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
Maintaining Friendships?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
Your day-to-day work?
- 1 None
- 2 Mild
- 3 Moderate
- 4 Severe
- 5 Extreme or cannot do
Overall, in the past 30 days, how many days were these difficulties present?
In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health conditions?
In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?
If you do not receive a call from a staff within 2 days of submitting your paperwork please contact your local Northland Counseling Center location to ensure they have received your paperwork. Please ensure you click submit.

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Northland Counseling Center, Inc.
Grand Rapids
Hibbing
International Falls
Kiesler Wellness Center
Aitkin

Northland Recovery Center, Inc.
Grand Rapids, MN
International Falls, MN

Northland Counseling Center Inc. does not discriminate in the provision of services to individuals based on their inability to pay, race, color, sex, national origin, disability, religion, or sexual orientation. It is the policy of Northland Counseling Center to provide essential medical services regardless of the patient’s ability to pay. Discounts are offered based upon household income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using the federal poverty guidelines. Northland Counseling Center Inc. accepts Medicare, Medicaid, private and CHIP. We will work with you to determine insurance eligibility.