6 Wheelchair Skills Test Questionnaire (WSTQ) Version 52 For

6
Wheelchair Skills Test Questionnaire (WST-Q) Version 5.2 for Powered
Wheelchairs
Question
Answer
Name of the wheelchair user?
Date questionnaire completed (month, day, year)?
Did you complete the questionnaire yourself?
□ Yes
□ No
If you had help, what is the name of the person who helped you?
If you had help, what is the relationship between you and the person
who helped you?
□ Family member
□ Friend
□ Caregiver
□ Other person
Do the answers for the questionnaire reflect your situation alone, or
with the assistance of your caregiver (if any)
□ Alone
□ Caregiver assisted
Introduction to the questionnaire
*
Copies of this questionnaire can be downloaded from
www.wheelchairskillsprogram.ca/eng/wstq.php.
*
More details about the questionnaire can be found there in the WSP
Manual.
*
In this questionnaire, you will be asked questions about different
skills that you might do in your wheelchair. These skills range
from ones that are more basic at the beginning to those that are
more advanced at the end.
*
There are no “right” or “wrong” answers. The purpose of the
questionnaire is simply to help us understand how you use your
wheelchair.
*
It will probably take about 10 minutes to complete the
questionnaire, but please take as much time as you need.
*
If you have more than one wheelchair, the questions are about the
wheelchair that you use most often.
*
If you have any comments, you will be able to record them at the
end of the questionnaire.
*
For each specific skill, beginning on page 3, you will be asked up
to three questions. The questions and the possible answers are
shown below.
*
If one of the purposes of this questionnaire is to assess if you
can perform each skill, you should answer the following question:
Performance question: “Could you do this skill today in your own
setting?”
Answer
Score
What this means
Yes, very well
3
I could do the skill safely and very well.
Yes, but not well
2
I could do the skill safely, but not well.
Yes, with help
1
I could direct a stranger to help me do it.
No
0
I have never done the skill or could not do it right now.
No part
NP
The wheelchair does not have the parts to allow this skill. (This
option is only presented for skills where such a score is a
possibility.)
*
If one of the purposes of this questionnaire is to assess how
confident you are in performing each skill, you should also answer
the following question:
Confidence question: “How confident are you that you could you do this
skill safely and consistently today in your own setting?”
Answer
Score
What this means
Very confident
3
I am very confident.
Somewhat confident
2
I am somewhat confident.
Somewhat unconfident
1
I am somewhat unconfident.
Very unconfident
0
I am very unconfident.
No part
NP
The wheelchair does not have the parts to allow this skill. (This
option is only presented for skills where such a score is a
possibility.)
*
If one of the purposes of this questionnaire is to assess how
often you do each skill, you should also answer the following
question:
Frequency question: “How often do you do this skill in your own
setting?”
Answer
Score
What this means
Always
3
Always when I need or want to do so.
Usually
2
Usually when I need or want to, but sometimes not.
Rarely
1
Rarely when I need or want to, but not usually.
Never
0
Never or less often than once a year.
No part
NP
The wheelchair does not have the parts to allow this skill. (This
option is only presented for skills where such a score is a
possibility.)
*
Please read the questions about specific skills that begin on the
next page. For each skill, record the answers in the spaces
provided.
Questions on Specific Skills
#
Skill Description
Questions
(Pick only one answer for each question)
Can you do it?
How confident are you?
How often do you do it?
1
Moving the controller out of the way and back.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
□ No part
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ No part
□ Always
□ Usually
□ Rarely
□ Never
□ No part
2
Turning the power on and off.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
3
Charging the battery
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
*
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
4
Disengaging the motors so the wheelchair can be pushed without
power and engaging them.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
*
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
5
Changing the program modes.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
□ No part
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ No part
□ Always
□ Usually
□ Rarely
□ Never
□ No part
6
Changing the speed setting.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
□ No part
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ No part
□ Always
□ Usually
□ Rarely
□ Never
□ No part
7
Operating other controller options, such as to control lights in
the room or to communicate.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
□ No part
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ No part
□ Always
□ Usually
□ Rarely
□ Never
□ No part
#
Skill Description
Questions
(Pick only one answer for each question)
Can you do it?
*
How confident are you?
How often do you do it?
8
Operating all of the positioning options of the wheelchair (for
example tilting the seat, reclining the seat, elevating the
leg-rests).
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
□ No part
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ No part
□ Always
□ Usually
□ Rarely
□ Never
□ No part
9
Moving the wheelchair forward, for example along a hallway.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
10
Moving the wheelchair backward, for example to back away from a
table.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
11
Turning the wheelchair around in a small space so that it is
facing in the opposite direction.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
12
Turning the wheelchair around obstacles while moving forward.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
13
Turning the wheelchair around obstacles while moving backward.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
14
Moving the wheelchair sideways in a small space, for example to
get the side of your wheelchair next to a kitchen counter, and
then back to where you started.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
#
Skill Description
Questions
(Pick only one answer for each question)
Can you do it?
How confident are you?
How often do you do it?
15
Picking a small object up from the ground (for example a cell
phone). Also, reaching an overhead object (for example something
on a shelf).
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
16
Shifting the weight from your sitting surfaces.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
17
Transferring from the wheelchair to a bench that is about the
same height as the wheelchair and then getting back into the
wheelchair.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
18
Getting down on the ground, then back into the wheelchair.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
19
Opening a hinged door, moving the wheelchair through it and
closing it behind you, then coming back the other way.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
20
Moving the wheelchair up a slight incline, for example a
standard ramp.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
21
Moving the wheelchair down a slight incline under control.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
22
Moving the wheelchair up a steep incline (about twice as steep
as a standard ramp).
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
23
Moving the wheelchair down a steep incline under control.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
24
Moving the wheelchair across a slight side-slope, for example
when crossing a driveway.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
25
Moving the wheelchair across a soft surface, for example grass.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
26
Getting the wheelchair over an obstacle that sticks up above the
surface, for example a high door threshold.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
27
Getting the wheelchair over a gap, for example a rut in the road
that is too big to simply roll over.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
28
Getting the wheelchair up a low curb, for example when entering
a building.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
29
Getting the wheelchair down from a low curb.
□ Yes, very well
□ Yes, but not well
□ Yes, with help
□ No
*
□ Very confident
*
□ Somewhat confident
*
□ Somewhat unconfident
□ Very unconfident
□ Always
□ Usually
□ Rarely
□ Never
If you have any general comments about the questions that you have
answered above, please record them in the space available below.
This is the end of the questionnaire. Thank you for completing it.
WST-Q 5.2 for Powered Wheelchairs
Originally approved for distribution and use: August 24, 2021
Current version: August 24, 2021