Please answer the questions to the best of your ability. We are trying to see what your activity level is like before and after physiotherapy.
Can you:

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* 1. Take care of yourself that is eating, dressing, bathing, or using the toilet?

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* 2. Walk indoors, such as around the house?

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* 3. Walk a block or two on level ground?

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* 4. Climb a flight of stairs, or walk up a hill?

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* 5. Run a short distance

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* 6. Do light work around the house e.g. dusting, washing dishes

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* 7. Do moderate work around the house like vacuuming, sweeping the floors, or carrying in the groceries?

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* 8. Can you do heavy work around the house, such as scrubbing floors or lifting and moving heavy furniture?

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* 9. Can you do yard work, such as raking leaves, weeding or pushing a power mower?

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* 10. Can you have sexual relations?

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* 11. Can you participate in moderate recreational activities, such as golf, bowling, dancing, doubles tennis or throwing a baseball or football?

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* 12. Can you participate in strenuous sports, such as swimming, singles tennis, football, basketball or skiing?

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