Protocol - Stroke Impact Scale (SIS) - Adults

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?

5

4

3

2

1

b. Grip of your hand that was most affected by your stroke?

5

4

3

2

1

c. Leg that was most affected by your stroke?

5

4

3

2

1

d. Foot/ankle that was most affected by your stroke?

5

4

3

2

1

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?

5

4

3

2

1

b. Remember things that happened the day before?

5

4

3

2

1

c. Remember to do things (e.g. keep scheduled appointments or take medication)?

5

4

3

2

1

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

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?

5

4

3

2

1

c. Feel that you are a burden to others?

5

4

3

2

1

d. Feel that you have nothing to look forward to?

5

4

3

2

1

e. Blame yourself for mistakes that you made?

5

4

3

2

1

f. Enjoy things as much as ever?

5

4

3

2

1

g. Feel quite nervous?

5

4

3

2

1

h. Feel that life is worth living?

5

4

3

2

1

i. Smile and laugh at least once a day?

5

4

3

2

1

4. In the past week, how difficult was it to...

Not difficult at all

A little difficult

Somewhat difficult

Very difficult

Extremely difficult

a. Say the name of someone who was in front of you?

5

4

3

2

1

b. Understand what was being said to you in a conversation?

5

4

3

2

1

c. Reply to questions?

5

4

3

2

1

d. Correctly name objects?

5

4

3

2

1

e. Participate in a conversation with a group of people?

5

4

3

2

1

f. Have a conversation on the telephone?

5

4

3

2

1

g. Call another person on the telephone, including selecting the correct phone number and dialing?

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)?

5

4

3

2

1

g. Control your bowels (not have an accident)?

5

4

3

2

1

h. Do light household tasks/chores (e.g. dust, make a bed, take out garbage, do the dishes)?

5

4

3

2

1

i. Go shopping?

5

4

3

2

1

j. Do heavy household chores (e.g. vacuum, laundry or yard work)?

5

4

3

2

1

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?

5

4

3

2

1

b. Stay standing without losing your balance?

5

4

3

2

1

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)?

5

4

3

2

1

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)?

5

4

3

2

1

e. Your role as a family member and/or friend?

5

4

3

2

1

f. Your participation in spiritual or religious activities?

5

4

3

2

1

g. Your ability to control your life as you wish?

5

4

3

2

1

h. Your ability to help others?

5

4

3

2

1

_______

100 Full Recovery

____

_______

90

____

_______

80

____

_______

70

____

_______

60

____

_______

50

____

_______

40

____

_______

30

____

_______

20

____

_______

10

____

_______

0 No Recovery