Name
*
First Name
Last Name
Email
*
1. Today, do you or would you have any difficulty at all with your usual work, housework or school activities?
*
2. Today, do you or would you have any difficulty at all with your usual hobbies, recreational or sporting activities?
*
3. Today, do you or would you have any difficulty at all with lifting a bag of groceries to waist level?
*
4. Today, do you or would you have any difficulty at all with lifting a bag of groceries above your head?
*
5. Today, do you or would you have any difficulty at all with grooming your hair?
*
6. Today, do you or would you have any difficulty at all with pushing up from your hands (eg from bathtub to chair)?
*
7. Today, do you or would you have any difficulty at all with preparing food (eg peeling, cutting)?
*
8. Today, do you or would you have any difficulty at all with driving?
*
9. Today, do you or would you have any difficulty at all with vacuuming, sweeping or raking?
*
10. Today, do you or would you have any difficulty at all with dressing?
*
11. Today, do you or would you have any difficulty at all with doing up buttons?
*
12. Today, do you or would you have any difficulty at all with using tools or appliances?
*
13. Today, do you or would you have any difficulty at all with opening doors?
*
14. Today, do you or would you have any difficulty at all with cleaning?
*
15. Today, do you or would you have any difficulty at all with tying or lacing shoes?
*
16. Today, do you or would you have any difficulty at all with sleeping?
*
17. Today, do you or would you have any difficulty at all with laundering clothes (washing, ironing, folding)?
*
18. Today, do you or would you have any difficulty at all with opening jar?
*
19. Today, do you or would you have any difficulty at all with throwing a ball?
*
20. Today, do you or would you have any difficulty at all with carrying a small suitcase with your affected limb?
*
