The following questions are about everyday activities. Please record what you have done in the last month. If you have not done an activity in the last month because you are not able to do it, then please put a “x” in “I am unable to manage this”. If you have the ability to do it, but have not done it, for example the weather has been too bad for gardening, please put an “x” in “Not applicable”

Walk around outside?
Climb stairs?
Get in and out of a car?
Walk over uneven ground?
Cross roads?
Travel on public transport?
Manage to feed yourself?
Manage to make yourself a hot drink?
Take hot drinks from one room to
another?
Do the washing up?
Make yourself a hot snack?
Manage your own money when out?
Wash small items of clothing?
Do your own housework?
Do your own shopping?
Do a full clothes wash?
Read newspapers or books?
Use the phone?
Write letters?
Go out socially?
Manage your own garden?
Drive a car?

For each task:
I can do this myself
I can do this myself but with difficulty
I need help with this
I am unable to manage this
Not applicable