The following questions are about activities you might do during a typical day. Does your health limit you in
these activities? If so how much?

a) Vigorous activities, such as running, lifting heavy
objects, participating in strenuous sports
b) Moderate activities, such as moving a table, pushing a
vacuum, bowling or playing golf
c) Lifting or carrying groceries 1 2 3
d) Climbing several flights of stairs 1 2 3
e) Climbing one flight of stairs 1 2 3
f) Bending, kneeling or stooping 1 2 3
g) Walking more than a mile 1 2 3
h) Walking several hundred yards 1 2 3
i) Walking one hundred yards 1 2 3
j) Bathing and dressing yourself