Item	No Difficulty	Some Difficulty	Much Difficulty	Unable to Do
1. Walking for a quarter of a mile; that is about 2 or 3 blocks?	1	2	3	4
2. Walking up 10 steps without resting?	1	2	3	4
3. Stooping, crouching, kneeling?	1	2	3	4
4. Lifting or carrying something as heavy as 10 pounds; like a sack of potatoes or rice?	1	2	3	4
5. Doing chores around the house like vacuuming, sweeping, dusting or straightening up?	1	2	3	4
6. Preparing your own meals?	1	2	3	4
7. Walking from one room to another on the same level?	1	2	3	4
8. Standing up from an armless straight chair?	1	2	3	4
9. Getting in and out of bed?	1	2	3	4
10. Eating, like holding a fork, cutting food or drinking from a glass?	1	2	3	4
11. Dressing yourself, including tying shoes, working zippers, and doing buttons?	1	2	3	4
12. Standing or being on your feet for about 2 h?	1	2	3	4
13. Sitting for about 2 h?	1	2	3	4
14. Reaching up over your head?	1	2	3	4
15. Using fingers to grasp or handle small objects?	1	2	3	4
16. Going out to things like shopping, movies, or sporting events?	1	2	3	4
17. Participating in social activities such as visiting friends, attending clubs or meetings, or going to parties?	1	2	3	4
18. Doing things to relax at home or for leisure such as reading, watching TV, sewing, or listening to music?	1	2	3	4
19. Pushing or pulling large objects like a living room chair?	1	2	3	4