Doesn’t Limit at All	Limits a Little	Limits Moderately	Limits Very Much
Full body hygiene	1□	2□	3□	4□
Dressing	1□	2□	3□	4□
Preparing and eating meals	1□	2□	3□	4□
Medication taking	1□	2□	3□	4□
Moving around the house	1□	2□	3□	4□
Reading and watching TV	1□	2□	3□	4□
Shopping	1□	2□	3□	4□
Commuting	1□	2□	3□	4□
Driving	1□	2□	3□	4□
Dealing with official matters	1□	2□	3□	4□