Physical Function

* 1. First Name

* 2. Last Name

* 3. Because of my weight I have trouble picking up objects.

* 4. Because of my weight I have trouble tying my shoes.

* 5. Because of my weight I have difficulty getting up from chairs.

* 6. Because of my weight I have trouble using stairs.

* 7. Because of my weight I have difficulty putting on or taking off my clothing.

* 8. Becaues of my weight I have trouble with mobility.

* 9. Because of my weight I have trouble crossing my legs.

* 10. I feel short of breath with only mild exertion.

* 11. I am troubled by painful or stiff joints.

* 12. My ankles and lower legs are swollen at the end of the day.

* 13. I am worried about my health.

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