1. Do you usually manage to get up and down stairs or steps…
2. Do you usually manage to get around the house (except for any stairs)…
3. Do you usually manage to get in and out of bed…
4. Do you usually manage to cut your toenails..
5. Do you usually manage to bath, shower or wash all over…
6. Do you usually manage to go out of doors and walk down the road…
7. Do you manage to use the toilet, including getting up and down
8. Do you manage to eat, including cutting up food..
9. Do you manage to wash your face and hands..
10. Do you manage to dress or undress, including putting on shoes and socks…
11. Do you manage to take the right amount of medicine at the right times…
12. Do you manage to shop for food, including getting to the shops, choosing the items, carrying the items home and then unpacking and putting the items away…
12. Do you manage to do routine housework or laundry…
13. Do you manage to do paperwork or paying bills…

For each 1-13 = ‘on your own’,
a. Do you find it very easy, fairly easy, fairly difficult or very difficult to do this on your own?

Q1-13
1.On your own
2. Only with help from someone else
3. or Not at all?

Qa
1. Very easy
2. Fairly easy
3. Fairly difficult
4. Very difficult

1. Asthma
2. Arthritis
3. Congestive heart failure
4. Coronary heart disease
5. Angina
6. Heart attack or myocardial infarction
7. Stroke
8. Emphysema
11. Chronic bronchitis
21. COPD (Chronic Obstructive Pulmonary Disease)
10. Hypothyroidism or an under-active thyroid
12. Any kind of liver condition
13. Cancer or malignancy
14. Diabetes
15. Epilepsy
16. High blood pressure/hypertension
22. An emotional, nervous or psychiatric problem.
19. Multiple Sclerosis
20. H.I.V.
18. Other long standing/chronic condition
96. None of these