Can you get to places out of walking During the past four weeks, how much distance without help? (For example, bodily pain have you had? can you travel alone on buses, taxis, or No pain.  drive your own car?) Mild pain.  Yes. No. Moderate pain.    Severe pain.  Are you having driving your car? Yes. No.   Do you exercise for about 20 minutes Not applicable, I do not use a car.  three or more days a week? Never.  Can you go shopping for groceries or Sometimes.  clothes without someone’s help? Frequently.  Always.  Yes. No.   Do you always fasten your seat belt when Can you do your housework without you are in a car? help? Yes. No.   Yes. No.   Can you prepare your own meals? Have you fallen two or more times in Yes. No. the past year?   Yes. No.   How often do you have trouble taking medicines the way you have been told to Are you afraid of falling? take them? Yes. No.   Never.  Sometimes.  Frequently.  Have you been given any information to Always.  help you with the following: Hazards in your house that might hurt you? Yes. No. Can you handle your own money without   help? Keeping track of your medications? Yes. No.   Yes. No.   Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house? Yes. No.  
During the past four weeks, how much bodily pain have you had?  No pain.  Mild pain.  Moderate pain.  Severe pain. Do you exercise for about 20 minutes three or more days a week?  Never.  Sometimes.  Frequently.  Always. Do you always fasten your seat belt when you are in a car?  Yes.  No. Have you fallen two or more times in the past year?  Yes.  No. Are you afraid of falling?  Yes.  No. Have you been given any information to help you with the following: Hazards in your house that might hurt you?  Yes.  No. Keeping track of your medications?  Yes.  No. Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house?  Yes.  No. Can you get to places out of walking distance without help? (For example, can you travel alone on buses, taxis, or drive your own car?)  Yes.  No. Are you having driving your car?  Yes.  No.  Not applicable, I do not use a car. Can you go shopping for groceries or clothes without someone’s help?  Yes.  No. Can you do your housework without help?  Yes.  No. Can you prepare your own meals?  Yes.  No. How often do you have trouble taking medicines the way you have been told to take them?  Never.  Sometimes.  Frequently.  Always. Can you handle your own money without help?  Yes.  No.