1. Are you able to get in and out of bed?
(If uses aids or appliances but also needs someone to help them, code as “I am unable to do this myself, I need someone else’s help”

2. What is the cause of your difficulty?

Part 1:
1. I have no difficulty doing this by myself
2. I have some difficulty doing this by myself
3. I can only do this by myself if I use an aid or appliance
4. I am unable to do this by myself, I need someone else’s help

Part 2:
(Up to 4 reasons may be specified)

General health
Hearing
Eyesight
Blood pressure – sitting
Smoking
Hand grip strength