Part 1:
Does this/Do any of these condition(s) or illness(es) affect CM_FirstName in any of the following areas?

Part 2:
Does this/Do any of these condition(s) or illness(es) reduce CM_FirstName’s ability to carry out day-to-day activities?  Would you say…

Part 1:
1 Vision (for example blindness or partial sight)  
2 Hearing (for example deafness or partial hearing)  
3 Mobility (for example walking short distances or climbing stairs)  
4 Dexterity (for example lifting and carrying objects, using a keyboard)  
5 Learning or understanding or concentrating  
6 Memory  
7 Mental health  
8 Stamina or breathing or fatigue  
9 Socially or behaviourally (for example associated with autism, attention deficit disorder or Asperger’s Syndrome)  
10 Other (please write in the box below) {VARNAME PXCLSO 200} 
11 {EXCLUSIVE}: None of these

Part 2:
1 Yes, a lot,  
2 Yes, a little  
3 Not at all