Never/Rarely When Doing This Task/Action (<1 Day)	Some or Little of the Time When Doing This Action/Task (1–2 Days)	Often or a Moderate Amount of Time When Doing This Action/Task (3–4 Days of the Week)	Most or All the Time When Doing This Action/Task (5 or More Days of the Week)
Question 1: Over the past week, on average, how often did you have problems with your physical balance (i.e., frequent loss of balance or unsteadiness or feel like you might fall while walking, running or standing still, etc.)?	☐	☐	☐	☐
Question 2: Over the past week, on average, how often did you have hand-eye coordination problems (e.g., several typos when typing on your phone or computer keyboard, several mistakes when playing an instrument while reading sheet music, reading and miswriting, mis put key into door lock to unlock the door, making small mistakes when playing a sport with the hands, etc.)?	☐	☐	☐	☐
Question 3: Over the past week, how often have you accidentally bumped your head into things (i.e., hitting the top of your head when getting out of the car, bumping your head into a kitchen cupboard, etc.)?	☐	☐	☐	☐
Question 4: Over the past week, how often have you bumped into people or objects/things (i.e., table, wall, chair or leg of a chair, etc.) with other parts of your body?	☐	☐	☐	☐
Question 5: Over the past week, how often have you missed when you reached for an object without looking (e.g., phone, water bottle, cup, pen, book, kitchen tools, keys, etc.)?	☐	☐	☐	☐
Question 6: Over the past week, how often did you fail to pick something up that you initially dropped (i.e., slipped out of your hands or butter fingers, etc.)?	☐	☐	☐	☐
Question 7: Over the past week, how often have you missed when you had to use your leg or foot (i.e., misplaced or awkward step when walking or walking up/down the staircase or stepping up to a chair or stool, missed when kicking a ball or putting your foot in slip-on shoes, pushing against the gas pedal instead of the brake pedal, etc.)?	☐	☐	☐	☐
Question 8: Over the past week, how often have struggled to perform a movement you normally do well (e.g., missed when hitting or catching a ball, tripped while walking or running, struggled with a musical instrument you normally play well, pushing against the gas or brake pedal too hard or soft, biting the side of your mouth, lip or tongue while eating, etc.)?	☐	☐	☐	☐
Question 9: Over the past week, how often have you had trouble recognizing familiar sounds that you normally recognize very quickly (e.g., mishearing words or phrases when someone is speaking to you or mishearing lyrics of a familiar song)?	☐	☐	☐	☐
Question 10: Over the past week, how often have you had trouble recognizing familiar objects, places or people that you normally recognize very quickly (e.g., recognizing that a cat ran past as opposed to just a fast-moving object or recognizing familiar face(s) when you walk past them at the grocery store, in the hallways at work or school, or recognize the place that you frequently pass by, etc.)?	☐	☐	☐	☐
Question 11: Over the past week, how often have you been having difficulties concentrating in situations where there is a lot of background noise (e.g., people coughing, side conversations around you, driving while listening to music and passengers having a conversation with you, etc.)?	☐	☐	☐	☐
Question 12: Over the past week, how often have you had difficulties performing tasks that require you to combine information from more than one sense (sound, sight, smell, taste, etc.) at the same time (i.e., you aren’t as fast at combining sight and sound information from traffic so you have difficulty gauging how much time you have to cross the street, or during online gaming; or food is not smelling and tasting as it used to, or you are not as accurate at judging the space available to pass thorough an opening so you bump into things, etc.)?	☐	☐	☐	☐