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

Part 2:
Does this/Do any of these condition(s) or illness(es) reduce your ability to carry out day-to-day
activities?

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 SPECIFY) {VARNAME PCLSO 200}
11 {EXCLUSIVE} None of these

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