Name:____________________________________Date:_______________________ Can you….. Yes, with no Yes, with No, I cant Don’t do this difficulty. some do this. For other difficulty. reasons. 1.Take care of yourself by ○ ○ ○ ○ eating,dressing,bathing,toileting? 2. Walk indoors such as around the ○ ○ ○ ○ house? 3. Walk a block on level ground? ○ ○ ○ ○ 4. Climb a flight of stairs or walk up ○ ○ ○ ○ hill? 5. Run a short distance? ○ ○ ○ ○ 6. Do light housework such as ○ ○ ○ ○ dusting or washing dishes? 7. Do moderate housework: ○ ○ ○ ○ vacuuming, sweeping, or carrying groceries? 8. Do heavy housework such as ○ ○ ○ ○ scrubbing floors or moving furniture? 9. Do yard work such as raking, ○ ○ ○ ○ weeding, or pushing a mower? 10. Have sexual relations? ○ ○ ○ ○ 11.Moderate Exercise such as golf, ○ ○ ○ ○ bowl, doubles tennis, throw ball? 12.Strenuous Exercise such as ○ ○ ○ ○ swim, ski, singles tennis, football, basketball? Total Score__________
Name:____________________________________Date:_______________________ Can you….. Yes, with no difficulty. Yes, with some difficulty. No, I cant do this. Don’t do this For other reasons. 1.Take care of yourself by eating,dressing,bathing,toileting? ○ ○ ○ ○ 2. Walk indoors such as around the house? ○ ○ ○ ○ 3. Walk a block on level ground? ○ ○ ○ ○ 4. Climb a flight of stairs or walk up hill? ○ ○ ○ ○ 5. Run a short distance? ○ ○ ○ ○ 6. Do light housework such as dusting or washing dishes? ○ ○ ○ ○ 7. Do moderate housework: vacuuming, sweeping, or carrying groceries? ○ ○ ○ ○ 8. Do heavy housework such as scrubbing floors or moving furniture? ○ ○ ○ ○ 9. Do yard work such as raking, weeding, or pushing a mower? ○ ○ ○ ○ 10. Have sexual relations? ○ ○ ○ ○ 11.Moderate Exercise such as golf, bowl, doubles tennis, throw ball? ○ ○ ○ ○ 12.Strenuous Exercise such as swim, ski, singles tennis, football, basketball? ○ ○ ○ ○ Total Score__________