The following items are about activities you might do during a typical day.

Does your health now limit you in these activities? If so, please indicate how much?
(One tick for each row)

For each response option:
Yes limited a lot
Yes limited a little
No, not limited at al

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