Name
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First Name
Last Name
Email
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1. Today, do you or would you have any difficulty at all with any of your usual work, housework or school activities?
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2. Today, do you or would you have any difficulty at all with your usual hobbies, recreational or sporting activities?
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3. Today, do you or would you have any difficulty at all getting into or out of the bath?
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4. Today, do you or would you have any difficulty at all walking between rooms?
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5. Today, do you or would you have any difficulty at all with putting on your shoes or socks?
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5. Today, do you or would you have any difficulty at all with putting on your shoes or socks?
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6. Today, do you or would you have any difficulty at all with squatting?
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7. Today, do you or would you have any difficulty at all with lifting an object, like a bag of groceries from the floor?
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8. Today, do you or would you have any difficulty at all with performing light activities around your home?
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9. Today, do you or would you have any difficulty at all with performing heavy activities around your home?
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10. Today, do you or would you have any difficulty at all with getting into or out of a car?
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11. Today, do you or would you have any difficulty at all with walking two blocks?
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12. Today, do you or would you have any difficulty at all with walking a kilometre?
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13. Today, do you or would you have any difficulty at all with going up or down 10 stairs (about one flight of stairs)?
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14. Today, do you or would you have any difficulty at all with standing for one hour?
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15. Today, do you or would you have any difficulty at all with sitting for one hour?
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16. Today, do you or would you have any difficulty at all with running on even ground?
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17. Today, do you or would you have any difficulty at all with running on uneven ground?
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18. Today, do you or would you have any difficulty at all with making sharp turns while running fast?
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19. Today, do you or would you have any difficulty at all with hopping?
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20. Today, do you or would you have any difficulty at all with rolling over in bed?
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