* 1. Which type of assessment will this be?

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

  0 = Extreme Difficulty or Unable to Perform Activity 1 = Quite a Bit of Difficulty 2 = Moderate Difficulty 3 = A Little Bit of Difficulty 4 = No Difficulty
Any of your usual work, housework, or school activities
Your usual hobbies, recreational or sporting activities
Lifting a bag of groceries to waist level
Lifting a bag of groceries above your head
Grooming your hair
Pushing up on your hands (eg from bathtub or chair)
Preparing food (eg peeling, cutting)
Driving
Vacuuming, sweeping, or raking
Dressing
Doing up buttons
Using tools or appliances
Opening doors
Cleaning
Tying or lacing shoes
Sleeping
Laundering clothes (eg washing, ironing, folding)
Opening a jar
Throwing a ball
Carrying a small suitcase with your affected limb

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