This questionnaire asks about difficulties due to health conditions. Health conditions include diseases, illnesses, injuries, mental or emotional problems. The ability to remember difficulties is most accurate for the period of one month. Think back over the past 30 and answer all questions, taking into account use of all your normal assistive device(s), if applicable (e.g. hearing aid, cane, walker, etc.). You may experience changes in the degree of difficulty over 30. In these cases, give a rating that reflects your worst. Circle only one response for each of the rating scales: and. Physical Activities In the past 30, how much and how often was it difficult for you to 1. Remain on your feet for at least 20 minutes? None Mild Moderate 2. Walk a block (about 100 meters) on flat ground? None Mild Moderate 3. Walk up a steep slope (e.g. on a hill)? None Mild Moderate 4. Walk on uneven surfaces (e.g. grass, snow, dirt road, or sidewalk)? None Mild Moderate 5. Step up and down curbs? None Mild Moderate 6. Use stairs (e.g. 12-15 steps)? None Mild Moderate 7. Get into and out of a kneeling position? None Mild Moderate 8. Get into and out of squatting position? None Mild Moderate 9. Bend or twist your back? None Mild Moderate 10. Sit for at least 20 minutes? None Mild Moderate 11. Transfer to and from chair, toilet, car, etc.? None Mild Moderate 12. Drive a car? None Mild Moderate 2017/02/11 DRAFT Version 6 1
Physical Activities In the past 30, how much and how often was it difficult for you to 13. Pull open a heavy door? None Mild Moderate 14. Push a full grocery cart? None Mild Moderate 15. Lift 10 pounds? None Mild Moderate 16. Carry 10 pounds? None Mild Moderate 17. Work overhead for 10 minutes (e.g. organizing a high shelf in a closet)? None Mild Moderate 18. Pick up objects? None Mild Moderate 19. Handle objects? None Mild Moderate 20. Use a computer keyboard? None Mild Moderate 21. Look at a computer screen for at least 20 minutes? None Mild Moderate If you have any additional information about difficulties related to Physical Activities, please comment below. Examples: energy level, pain, good vs. bad, whether abilities have worsened or improved over time, etc. 2017/02/11 DRAFT Version 6 2
Behaviours and Emotions In the past 30, how much and how often did the following statements apply to you? Level of ment 1. I was comfortable trying different ways of doing things. 2. When I had to do a really difficult task, I kept at it until I got it done. 3. I looked at both sides of an issue. 4. It was hard to adjust to unexpected changes. 5. When I was stressed, I couldn't figure out what to do. 6. I had difficulty in dealing with people I did not know. 7. I was in conflict with others. 8. I got physically or verbally aggressive when I was angry. 9. It was easy to do what people in authority asked me to do. 10. I said or did things that other people probably thought were inappropriate. 11. I was unable to manage my anxiety. 12. I avoided public places or activities. 2017/02/11 DRAFT Version 6 3
If you have any additional information about difficulties related to Behaviours and Emotions, please comment below. Examples: energy level, pain, good vs. bad, whether abilities have worsened or improved over time, etc. Communication and Thinking In the past 30, how much and how often was it difficult for you to 1. Understand what people say? None Mild Moderate 2. Bring to mind words that you wanted to use while talking to someone? None Mild Moderate 3. Get your point across when talking with someone? None Mild Moderate 4. Remember to do important things (e.g. keeping appointments)? None Mild Moderate 5. Find your way to a familiar place? None Mild Moderate 6. Think clearly? None Mild Moderate 7. Think quickly? None Mild Moderate 8. Concentrate and focus your attention? None Mild Moderate 9. Keep track of what you are doing, even if you are interrupted? None Mild Moderate 10. Shift back and forth between two activities that require thinking? None Mild Moderate 2017/02/11 DRAFT Version 6 4
Communication and Thinking In the past 30, how much and how often was it difficult for you to 11. Learn new things? None Mild Moderate 12. Prioritize and plan? None Mild Moderate 13. Make decisions? None Mild Moderate 14. Start things? None Mild Moderate 15. Finish things? None Mild Moderate 16. Add and subtract numbers? None Mild Moderate 17. Read? None Mild Moderate 18. Express yourself in writing? None Mild Moderate If you have any additional information about difficulties related to Communication and Thinking, please comment below. Examples: energy level, pain, good vs. bad, whether abilities have worsened or improved over time, etc. 2017/02/11 DRAFT Version 6 5
Other Daily Activities In the past 30, how much and how often was it difficult for you to 1. Take care of your personal hygiene (e.g. bathing, brushing your teeth, combing your hair, shaving, etc.)? None Mild Moderate 2. Take medication(s) as directed and handle/store medication(s) safely? None Mild Moderate 3. Dress yourself in the way you want to be dressed (including buttoning clothes and putting on shoes)? None Mild Moderate 4. Feed yourself? None Mild Moderate 5. Get to the bathroom in time? None Mild Moderate 6. Do housekeeping and home maintenance (e.g. cleaning, laundry, meal preparation, shopping, yard work, snow clearing, etc.)? None Mild Moderate 7. Keep at tasks without frequent breaks? None Mild Moderate 8. Use a telephone? None Mild Moderate 9. Manage your financial affairs (e.g. budget and pay bills)? None Mild Moderate If you have any additional information about difficulties related to Other Daily Activities, please comment below. Examples: energy level, pain, good vs. bad, whether abilities have worsened or improved over time, etc. 2017/02/11 DRAFT Version 6 6