Please place a tick () in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to get around indoors (except steps) by yourself?

b. Do you usually manage to get in and out of a bed (or chair) by yourself?

c. Do you usually manage to feed yourself?

d. Do you usually deal with finances and paperwork – for example, paying bills, writing letters – by yourself?

Repeated response scale for all categories:
I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself