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The Stroke Impact Scale Version 3.0, a self-assessment questionnaire designed to evaluate the impact of a stroke on an individual's health and daily life. The questionnaire covers various aspects such as physical impairments, memory and thinking, mood, communication, and daily activities.
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Uploaded on 09/27/2022
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1. In the past week, how would you rate the strength of your....
A lot of strength
Quite a bit of strength
Some strength
A little strength
No strength at all a. Arm that was most affected by your stroke?
b. Grip of your hand that was most affected by your stroke?
c. Leg that was most affected by your stroke?
d. Foot/ankle that was most affected by your stroke?
2. In the past week, how difficult was it for you to...
Not difficult at all
A little difficult
Somewhat difficult
Very difficult
Extremely difficult
a. Remember things that people just told you?
b. Remember things that happened the day before?
c. Remember to do things (e.g. keep scheduled appointments or take medication)?
d. Remember the day of the week? 5 4 3 2 1 e. Concentrate? 5 4 3 2 1 f. Think quickly? 5 4 3 2 1 g. Solve everyday problems? 5 4 3 2 1
5. In the past 2 weeks, how difficult was it to...
Not difficult at all
A little difficult
Somewhat difficult
Very difficult
Could not do at all
a. Cut your food with a knife and fork? 5 4 3 2 1
b. Dress the top part of your body? 5 4 3 2 1
c. Bathe yourself? 5 4 3 2 1
d. Clip your toenails? 5 4 3 2 1
e. Get to the toilet on time? 5 4 3 2 1
f. Control your bladder (not have an accident)?
g. Control your bowels (not have an accident)?
h. Do light household tasks/chores (e.g. dust, make a bed, take out garbage, do the dishes)?
i. Go shopping? 5 4 3 2 1
j. Do heavy household chores (e.g. vacuum, laundry or yard work)?
6. In the past 2 weeks, how difficult was it to...
Not difficult at all
A little difficult
Somewhat difficult Very difficult
Could not do at all a. Stay sitting without losing your balance?
b. Stay standing without losing your balance?
c. Walk without losing your balance? 5 4 3 2 1
d. Move from a bed to a chair? 5 4 3 2 1
e. Walk one block? 5 4 3 2 1
f. Walk fast? 5 4 3 2 1
g. Climb one flight of stairs? 5 4 3 2 1
h. Climb several flights of stairs? 5 4 3 2 1
i. Get in and out of a car? 5 4 3 2 1
7. In the past 2 weeks, how difficult was it to use your hand that was most affected by your stroke to...
Not difficult at all
A little difficult
Somewhat difficult Very difficult
Could not do at all
a. Carry heavy objects (e.g. bag of groceries)?
b. Turn a doorknob? 5 4 3 2 1
c. Open a can or jar? 5 4 3 2 1
d. Tie a shoe lace? 5 4 3 2 1
e. Pick up a dime? 5 4 3 2 1
8. During the past 4 weeks, how much of the time have you been limited in...
None of the time
A little of the time
Some of the time
Most of the time
All of the time
a. Your work (paid, voluntary or other) 5 4 3 2 1
b. Your social activities? 5 4 3 2 1
c. Quiet recreation (crafts, reading)? 5 4 3 2 1
d. Active recreation (sports, outings, travel)?
e. Your role as a family member and/or friend?
f. Your participation in spiritual or religious activities?
g. Your ability to control your life as you wish?
h. Your ability to help others? 5 4 3 2 1
