|
Activities |
Extremely difficult or unable to perform activity |
Quite a bit of difficulty |
Moderate difficulty |
A little bit of difficulty |
No difficulty |
|
(1) |
Any of your usual work, housework, or school activities |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(2) |
Your usual hobbies, recreational or sporting activities |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(3) |
Getting into or out of the bath |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(4) |
Walking between rooms |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(5) |
Putting on your shoes or socks |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(6) |
Squatting |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(7) |
Lifting an object, like a bag of groceries, from the floor |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(8) |
Performing light activities around your home |
⬜ 0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(9) |
Performing heavy activities around your home |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(10) |
Getting into or out of a car |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(11) |
Walking 2 blocks |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(12) |
Walking a mile |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(13) |
Going up or down 10 stairs (about 1 flight of stairs) |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(14) |
Standing for 1 hour |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(15) |
Sitting for 1 hour |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(16) |
Running on even ground |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(17) |
Running on uneven ground |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(18) |
Making sharp turns while running fast |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(19) |
Hopping |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |
(20) |
Rolling over in bed |
⬜0 |
⬜1 |
⬜2 |
⬜3 |
⬜4 |