ACTIVITIES
1- Yes‚ limited a lot; 2-Yes‚ limited a little; 3-No‚ not limited at all
a. Vigorous activities‚ such as running‚ lifting heavy objects‚ participating in strenuous sports.
b. Moderate activities‚ such as moving a table‚ pushing a vacuum cleaner‚ bowling‚ or playing golf.
c. Lifting or carrying groceries
d. Climbing several flights of stairs
e. Climbing one flight of stairs
f. Bending‚ kneeling or stooping
g. Walking more than one mile
h. Walking several blocks
i. Walking one block
j. Bathing or dressing yourself
2. How satisfied are you with your physical ability to do what you want to do? (Circle One)
Completely satisfied . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Very satisfied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Somewhat satisfied. . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Somewhat dissatisfied . . . . . . . . . . . . . . . . . . . . . . . . 4
Very dissatisfied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Completely dissatisfied. . . . . . . . . . . . . . . . . . . . . . . . 6
3. When you travel around your community‚ does someone have to assist you because of your health? (Circle One)
Yes‚ all of the time . . . . . . . . . . . . . . . . . . . . . . . . . 1
Yes‚ most of the time . . . . . . . . . . . . . . . . . . . . . . . 2
Yes‚ some of the time . . . . . . . . . . . . . . . . . . . . . . . 3
Yes‚ a little of the time . . . . . . . . . . . . . . . . . . . . . . 4
No‚ none of the time . . . . . . . . . . . . . . . . . . . . . . . . 5
4. Are you in bed or in a chair most or all of the day because of your health? (Circle One)
Yes‚ every day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Yes‚ most days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Yes‚ some days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Yes‚ occasionally . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
No‚ never . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
5. Are you able to use public transportation?
(Circle One)
No‚ because of my health . . . . . . . . .. . . . . . . . . . . . 1
No‚ for some other reason . . . . . . . . . . . . . . . . . . . . 2
Yes‚ able to use public transportation . . . . . . . . . . . . 3