Physical Function	Without any difficulty	With a little difficulty	With some difficulty	With much difficulty	Unable to do
Are you able to do chores such as vacuuming or yard work?	□ 5	□ 4	□ 3	□ 2	□ 1
Are you able to go up and down stairs at a normal pace?	□ 5	□ 4	□ 3	□ 2	□ 1
Are you able to go for a walk of at least 15 minutes?	□ 5	□ 4	□ 3	□ 2	□ 1
Are you able to run errands and shop?	□ 5	□ 4	□ 3	□ 2	□ 1