* 1. Which type of assessment will this be?

* 2. Today, do you or would you have any difficulty at all with:

  Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty
Any of your usual work, housework, or school activities
Your usual hobbies, recreational or sporting activities
Getting into or out of the bath
Walking between rooms
Putting your shoes or socks on
Squatting
Lifting an object, like a bag of groceries from the floor
Performing light activities around your home
Performing heavy activities around your home
Getting into or out of a car
Walking 2 blocks
Walking a mile
going up or down 10 stairs (about one flight of stairs)
Standing for 1 hour
Sitting for 1 hour
Running on even ground
Running on uneven ground
Making sharp turns while running
Hopping
Rolling over in bed

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