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PhenX Measure: Functionality after Stroke (#820700) PhenX Protocol: Stroke Impact Scale (SIS) - Adults (#820701)
Date of Interview/Examination (MM/DD/YYYY): _____________________ Stroke Impact Scale
VERSION 3.
The purpose of this questionnaire is to evaluate how stroke has impacted your health and life. We want to know from YOUR POINT OF VIEW how stroke has affected you. We will ask you questions about impairments and disabilities caused by your stroke, as well as how stroke has affected your quality of life. Finally, we will ask you to rate how much you think you have recovered from your stroke.
These questions are about the physical problems which may have occurred as a result of your stroke.
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?
These questions are about your memory and thinking.
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?
e. Concentrate? 5 4 3 2 1
f. Think quickly? 5 4 3 2 1
g. Solve everyday problems?
These questions are about how you feel, about changes in your mood, and about your ability to control your emotions since your stroke.
3. In the past week, how often did you...
None of the time
A little of the time
Some of the time
Most of the time
All of the time
a. Feel sad? 5 4 3 2 1
b. Feel that there is nobody you are close to?
c. Feel that you are a burden to others?
d. Feel that you have nothing to look forward to?
e. Blame yourself for mistakes that you made?
f. Enjoy things as much as ever?
g. Feel quite nervous? 5 4 3 2 1
at all at all
a. Cut your food with a knife and fork?
b. Dress the top part of your body?
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)?
The following questions are about your ability to be mobile at home and in the community.
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?
d. Move from a bed 5 4 3 2 1
to a chair?
e. Walk one block? 5 4 3 2 1
f. Walk fast? 5 4 3 2 1
g. Climb one flight of stairs?
h. Climb several flights of stairs?
i. Get in and out of a car?
The following questions are about your ability to use your hand that was MOST AFFECTED by your stroke.
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
The following questions are about how stroke has affected your ability to participate in the activities that you usually do, things that are meaningful to you, and help you to find purpose in life.
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)?
b. Your social activities? 5 4 3 2 1
_______ 20
____
_______ 10
____
_______ 0 No Recovery
Scoring: Each item is rated in a 5-point Likert scale in terms of the difficulty the patient has experienced in completing each item. A score of 1 = an inability to complete the item and a score of 5 = no difficulty experienced at all. Summative scores are generated for each domain. Domain scores range from 0-100.
The Stroke Impact Scale (SIS) is scored in the following way, for each domain:
Transformed Scale = [(Actual raw score - lowest possible raw score) / Possible raw score range] x 100
Three items in the emotion domain, 3f, 3h, and 3i, are reverse-scored, i.e., 1 becomes 5, 2 becomes 4, 3 remains the same, 4 becomes 2, and 5 becomes 1, prior to manual calculation. For these items, use the following equation to compute the individual's score:
6 - individual's rating = item score
The last item assesses the participant's overall perception of recovery and is presented in the form of a visual analog scale from 0 to 100, where 0 = "no recovery" and 100 = "full recovery."
