3 Item Banks

Response Scale
Item #
Item
Interpersonal Interactions- Workplace
The following questions will be about your typical workplace activities or feelings

Entry Order

1F3

II978

Please specify your level of agreement: I get along easily with
my co-workers

strongly
agree

Agree

strongly
disagree

disagree

1F3

II977

Please specify your level of agreement: I can get along with my strongly
boss
agree

Agree

strongly
disagree

disagree

1F3

II353

Please specify your level of agreement: I expect a lot from my
co-workers

strongly
agree

Agree

strongly
disagree

disagree

1F3

II976

Please specify your level of agreement: I feel comfortable in
my work environment

strongly
agree

Agree

strongly
disagree

disagree

1F3

II975

Please specify your level of agreement: I feel comfortable
around my coworkers

strongly
agree

Agree

strongly
disagree

disagree

1F3

II639b

Please specify your level of agreement: I have to do my work in strongly
shorter periods of time than usual for me
agree

Agree

strongly
disagree

disagree

1F3

II431

Please specify your level of agreement: I easily finish all the
work that is given to me

strongly
agree

Agree

strongly
disagree

disagree

1F3

II509

Please specify your level of agreement: I can easily meet
deadlines

strongly
agree

Agree

strongly
disagree

disagree

1F3

II453

Please specify your level of agreement: I worry about how well strongly
I'm doing things
agree

Agree

strongly
disagree

disagree

1F3

II559

Please specify your level of agreement: I'm careful to avoid
physical contact at work except for shaking hands

Agree

strongly
disagree

disagree

strongly
agree

does not
apply to
me
does not
apply to
me
does not
apply to
me
does not
apply to
me
does not
apply to
me
does not
apply to
me
does not
apply to
me
does not
apply to
me
does not
apply to
me
does not
apply to
me

156

157

158

159

160

161

162

163

164

165

Interpersonal Interactions
Please choose the answer that best reflects your feelings or behaviors.
Filter: answer this
Item
item
#
Item
Entry order
The following questions have to do with your general attitudes or beliefs. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Please specify your level of agreement: Being honest is
strongly
strongly
I don't
II528
important to me
agree
Agree
disagree
disagree
know
1
Please specify your level of agreement: Doing things well is
strongly
strongly
I don't
II430
very important to me
agree
Agree
disagree
disagree
know
2
Please specify your level of agreement: Even when things are strongly
strongly
I don't
II604b
going badly I still have hope
agree
Agree
disagree
disagree
know
3
Please specify your level of agreement: I believe that things
strongly
strongly
I don't
II999
end up alright most of the time
agree
Agree
disagree
disagree
know
4
Please specify your level of agreement: I can get back on track strongly
strongly
I don't
II585
when I am distracted
agree
Agree
disagree
disagree
know
5
Please specify your level of agreement: I can put aside my
strongly
strongly
I don't
II998
worries to do what's important at the moment
agree
Agree
disagree
disagree
know
6
Please specify your level of agreement: I feel hopeless about
strongly
strongly
I don't
II094b
the future
agree
Agree
disagree
disagree
know
7

strongly
strongly
I don't
Please specify your level of agreement: I follow the rules
agree
Agree
disagree
disagree
know
8
Please specify your level of agreement: I have to do things my strongly
strongly
I don't
II590
way
agree
Agree
disagree
disagree
know
9
Please specify your level of agreement: I have to plan whatever strongly
strongly
I don't
II404
I do very carefully
agree
Agree
disagree
disagree
know
10
Please specify your level of agreement: I learn from my
strongly
strongly
I don't
II997
mistakes
agree
Agree
disagree
disagree
know
11
Please specify your level of agreement: I look at both sides of strongly
strongly
I don't
II526
an issue
agree
Agree
disagree
disagree
know
12
Please specify your level of agreement: I look for the good in strongly
strongly
I don't
II996
difficult situations
agree
Agree
disagree
disagree
know
13
Please specify your level of agreement: I never take something strongly
strongly
I don't
II144
that does not belong to me
agree
Agree
disagree
disagree
know
14
Please specify your level of agreement: I only start things I
strongly
strongly
I don't
II418
know I can finish
agree
Agree
disagree
disagree
know
15
Please specify your level of agreement: If I make a mistake, I
strongly
strongly
I don't
II462
know I can deal with it
agree
Agree
disagree
disagree
know
16
Please specify your level of agreement: I'm comfortable just
strongly
strongly
I don't
II995
seeing what the day brings
agree
Agree
disagree
disagree
know
17
Please specify your level of agreement: I'm comfortable trying strongly
strongly
I don't
II405
different ways to do things
agree
Agree
disagree
disagree
know
18
Please specify your level of agreement: Trying new things is
strongly
strongly
I don't
II407
fun
agree
Agree
disagree
disagree
know
19
Please specify your level of agreement: When I'm asked to do strongly
strongly
I don't
II432
a really difficult task, I keep at it until I get it done
agree
Agree
disagree
disagree
know
20
The following questions have to do with how you typically get along with others. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Please specify your level of agreement: I am able to keep a
strongly
strongly
I don't
II468
secret
agree
Agree
disagree
disagree
know
21
Please specify your level of agreement: I am comfortable
strongly
strongly
I don't
II561
making eye contact with others
agree
Agree
disagree
disagree
know
22
Please specify your level of agreement: I am good at making strongly
strongly
I don't
II334
new friends
agree
Agree
disagree
disagree
know
23
Please specify your level of agreement: I am resentful when I strongly
strongly
I don't
II284b
don't get my way
agree
Agree
disagree
disagree
know
24
Please specify your level of agreement: I am stubborn with
strongly
strongly
I don't
II026b
others
agree
Agree
disagree
disagree
know
25
Please specify your level of agreement: I am willing to accept strongly
strongly
I don't
II551
help from others
agree
Agree
disagree
disagree
know
26
strongly
strongly
I don't
II276
Please specify your level of agreement: I try to get attention
agree
Agree
disagree
disagree
know
27
Please specify your level of agreement: I try to understand why strongly
strongly
I don't
II415
others disagree with me
agree
Agree
disagree
disagree
know
28
Please specify your level of agreement: I usually know what
strongly
strongly
I don't
II560
others expect of me
agree
Agree
disagree
disagree
know
29
Please specify your level of agreement: I avoid getting into
strongly
strongly
I don't
II994
arguments with others
agree
Agree
disagree
disagree
know
30
Please specify your level of agreement: I can be resentful of
strongly
strongly
I don't
II256
others
agree
Agree
disagree
disagree
know
31
Please specify your level of agreement: I can easily begin
strongly
strongly
I don't
II397
talking with others
agree
Agree
disagree
disagree
know
32
Please specify your level of agreement: I can talk my way out strongly
strongly
I don't
II270
of anything
agree
Agree
disagree
disagree
know
33
II262

II484
II293
II492
II151
II538
II158
II020
II554
II027b
II206
II396
II248

II624b
II208
II395
II150
II467
II991
II989
II987
II537
II993
II992
II540
II619b
II501

Please specify your level of agreement: I can't stop myself
from being rude
Please specify your level of agreement: I do what I can to get
along with others
Please specify your level of agreement: I do whatever I want,
no matter what others think
Please specify your level of agreement: I feel people are
against me
Please specify your level of agreement: I feel sick when I have
to speak in front of people
Please specify your level of agreement: I feel that there are
people I can turn to
Please specify your level of agreement: I get along well with
people outside my family
Please specify your level of agreement: I get angry when I'm
told how to do something
Please specify your level of agreement: I get in conflicts with
others
Please specify your level of agreement: I get very loud when I
do not get what I want
Please specify your level of agreement: I have one close friend
and sometimes that is too many
Please specify your level of agreement: I respect other
people's point of view

strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree

Please specify your level of agreement: I say or do things that
other people probably think are inappropriate
Please specify your level of agreement: I sometimes get
physical when I'm angry
Please specify your level of agreement: I stay alone at home to
avoid people
Please specify your level of agreement: I think people are
watching me

strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree
strongly
agree

Please specify your level of agreement: I think people trust me
Please specify your level of agreement: Most people like what I
have to say
Please specify your level of agreement: People tell me I'm
polite
Please specify your level of agreement: When I'm angry, I take
a break until I can explain myself calmly
Please specify your level of agreement: I worry people are
criticizing me even when they are not
Please specify your level of agreement: I'm usually able to help
solve other people's problems
Please specify your level of agreement: It is easy for me to
keep a respectful distance from others
Please specify your level of agreement: It's better for me when
I can work alone
Please specify your level of agreement: Just being around
people irritates me
Please specify your level of agreement: People ask me to stop
interrupting them

Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree

Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree

strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree
strongly
disagree

disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree

disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree
disagree

I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know
I don't
know

34
35
36
37
38
39
40

Entry Order

41

116

42

117

43

118

44

119

45

120

46

121

47

122

48

123

49
50
51
52
53
54
55
56
57
58
59

Please specify your level of agreement: People know that I get strongly
strongly
I don't
angry easily
agree
Agree
disagree
disagree
know
60
Please specify your level of agreement: People tell me I'm
strongly
strongly
I don't
II990
flexible and agreeable
agree
Agree
disagree
disagree
know
61
Please specify your level of agreement: It's easy to do what
strongly
strongly
I don't
II324
people in authority ask me to do
agree
Agree
disagree
disagree
know
62
Please specify your level of agreement: I get in trouble for
strongly
strongly
I don't
II283
playing practical jokes or 'horsing around'
agree
Agree
disagree
disagree
know
63
Please specify your level of agreement: I've been told to stop strongly
strongly
I don't
II524
making racial, sexual, or religious jokes
agree
Agree
disagree
disagree
know
64
The following questions have to do with your typical feelings or emotions. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Please specify your level of agreement: I am fairly evenstrongly
strongly
I don't
II443
tempered most of the time
agree
Agree
disagree
disagree
know
65
Please specify your level of agreement: I am so tired that I rest strongly
strongly
I don't
II986
or sleep most of the day
agree
Agree
disagree
disagree
know
66
Please specify your level of agreement: I am so tired when I
strongly
strongly
I don't
II474
wake up, it's hard to get going
agree
Agree
disagree
disagree
know
67
Please specify your level of agreement: I am unable to think
strongly
strongly
I don't
II498
with all the noise in my head
agree
Agree
disagree
disagree
know
68
Please specify your level of agreement: I can't stop myself
strongly
strongly
I don't
II493
from doing the same thing over and over
agree
Agree
disagree
disagree
know
69
Please specify your level of agreement: I can't wait to enjoy
strongly
strongly
I don't
II985
something special
agree
Agree
disagree
disagree
know
70
Please specify your level of agreement: I don't know why I cry strongly
strongly
I don't
II984
so often
agree
Agree
disagree
disagree
know
71
strongly
strongly
I don't
II983
Please specify your level of agreement: I dwell on my problems agree
Agree
disagree
disagree
know
72
Please specify your level of agreement: I feel emotionally
strongly
strongly
I don't
II607b
exhausted
agree
Agree
disagree
disagree
know
73
Please specify your level of agreement: I feel good about
strongly
strongly
I don't
II139
myself
agree
Agree
disagree
disagree
know
74
Please specify your level of agreement: I feel that nothing can strongly
strongly
I don't
II605b
cheer me up
agree
Agree
disagree
disagree
know
75
strongly
strongly
I don't
II164
Please specify your level of agreement: I have a lot of energy agree
Agree
disagree
disagree
know
76
Please specify your level of agreement: I have difficulty
strongly
strongly
I don't
II601b
calming down
agree
Agree
disagree
disagree
know
77
Please specify your level of agreement: I have good control of strongly
strongly
I don't
II230b
my emotions
agree
Agree
disagree
disagree
know
78
Please specify your level of agreement: I have trouble
strongly
strongly
I don't
II615b
controlling my temper
agree
Agree
disagree
disagree
know
79
Please specify your level of agreement: I have trouble enjoying strongly
strongly
I don't
II608b
the things I used to enjoy
agree
Agree
disagree
disagree
know
80
Please specify your level of agreement: I have trouble paying strongly
strongly
I don't
II617b
attention
agree
Agree
disagree
disagree
know
81
Please specify your level of agreement: It Is hard to adjust to strongly
strongly
I don't
II618b
unexpected changes
agree
Agree
disagree
disagree
know
82
Please specify your level of agreement: It is hard to keep up
strongly
strongly
I don't
II609b
enthusiasm to get things done
agree
Agree
disagree
disagree
know
83
Please specify your level of agreement: Many situations make strongly
strongly
I don't
II597b
me worry
agree
Agree
disagree
disagree
know
84
Please specify your level of agreement: Sometimes I shout or strongly
strongly
I don't
II212
yell for no reason
agree
Agree
disagree
disagree
know
85
II257

Please specify your level of agreement: When I feel myself
strongly
strongly
I don't
becoming too sad, I shake it off and keep going
agree
Agree
disagree
disagree
know
86
Please specify your level of agreement: When I get frustrated I strongly
strongly
I don't
II229b
let it show
agree
Agree
disagree
disagree
know
87
Please specify your level of agreement: When I'm stressed, I
strongly
strongly
I don't
II505
can't figure out what to do
agree
Agree
disagree
disagree
know
88
Please specify your level of agreement: Sometimes I do things strongly
strongly
I don't
II485
to hurt myself when I'm angry
agree
Agree
disagree
disagree
know
89
The following questions about your family and community activities. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Please specify your level of agreement: I look forward with
strongly
strongly
I don't
II626b
enjoyment to upcoming events
agree
Agree
disagree
disagree
know
90
Please specify your level of agreement: I like large family
strongly
strongly
I don't
II982
gatherings
agree
Agree
disagree
disagree
know
91
Please specify your level of agreement: I am able to do all the strongly
strongly
I don't
II629b
family activities that I am expected to do
agree
Agree
disagree
disagree
know
92
Please specify your level of agreement: I am able to maintain strongly
strongly
I don't
II630b
my friendships as much as I would like
agree
Agree
disagree
disagree
know
93
Please specify your level of agreement: I avoid public places or strongly
strongly
I don't
II635b
activities
agree
Agree
disagree
disagree
know
94
Please specify your level of agreement: I enjoy doing things
strongly
strongly
I don't
II981
with my family
agree
Agree
disagree
disagree
know
95
Please specify your level of agreement: It's easy for me to plan strongly
strongly
I don't
II980
activities with friends
agree
Agree
disagree
disagree
know
96
Please specify your level of agreement: I feel that I'm an
strongly
strongly
I don't
II979
important part of the community where I live
agree
Agree
disagree
disagree
know
97
Please specify your level of agreement: I know my family or
strongly
strongly
I don't
II392
friends care about me no matter what
agree
Agree
disagree
disagree
know
98
The following questions about how you've felt in the past 7 days. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
In the past 7 days, I have been doing fewer social activities in
II593
groups than is usual for me
never
rarely
sometimes often
always
99
II442

II026

In the past 7 days, I was stubborn with others

never

rarely

sometimes often

always

100

II027

In the past 7 days, I was in conflict with others

never

rarely

sometimes often

always

101

II038

In the past 7 days, I felt like yelling at someone

never

rarely

sometimes often

always

102

II594

In the past 7 days, I felt indecisive

never

rarely

sometimes often

always

103

II229

In the past 7 days, When I was frustrated I let it show

never

rarely

sometimes often

always

104

II596

In the past 7 days, I had sudden feelings of panic

never

rarely

sometimes often

always

105

II230

In the past 7 days, I had good control of my emotions

never

rarely

sometimes often

always

106

II597

In the past 7 days, Many situations made me worry

never

rarely

sometimes often

always

107

II591

In the past 7 days, I felt something awful would happen

never

rarely

sometimes often

always

108

II599

In the past 7 days, I became easily upset

never

rarely

sometimes often

always

109

II600

In the past 7 days, I suddenly became emotional for no reason never

rarely

sometimes often

always

110

II601

In the past 7 days, I had difficulty calming down

rarely

sometimes often

always

111

never

II094

In the past 7 days, I felt hopeless about the future

never

rarely

sometimes often

always

112

II583

In the past 7 days, I was afraid of what the future holds for me never

rarely

sometimes often

always

113

II602

In the past 7 days, I felt that I had nothing to look forward to

never

rarely

sometimes often

always

114

II603

never

rarely

sometimes often

always

115

II604

In the past 7 days, I felt that nothing was interesting
In the past 7 days, Even when things were going badly I still
had hope

never

rarely

sometimes often

always

116

II605

In the past 7 days, I felt that nothing could cheer me up

never

rarely

sometimes often

always

117

II606

In the past 7 days, I was critical of myself for my mistakes

never

rarely

sometimes often

always

118

II607

In the past 7 days, I felt emotionally exhausted
In the past 7 days, I had trouble enjoying the things I used to
enjoy
In the past 7 days, It was hard to keep up enthusiasm to get
things done

never

rarely

sometimes often

always

119

never

rarely

sometimes often

always

120

never

rarely

sometimes often

always

121

never

rarely

sometimes often

always

122

never

rarely

sometimes often

always

123

II612

In the past 7 days, I get fidgety
In the past 7 days, When I was mad at someone I gave them
the silent treatment
In the past 7 days, I tried to get even when I was angry at
someone

never

rarely

sometimes often

always

124

II613

In the past 7 days, I held grudges toward others

never

rarely

sometimes often

always

125

II614

In the past 7 days, I stayed angry for hours

never

rarely

sometimes often

always

126

II615

In the past 7 days, I had trouble controlling my temper

never

rarely

sometimes often

always

127

II616

In the past 7 days, I was preoccupied with my worries

never

rarely

sometimes often

always

128

II617

rarely

sometimes often

always

129

II592

In the past 7 days, I had trouble paying attention
never
In the past 7 days, I felt nervous when my normal routine was
disturbed
never

rarely

sometimes often

always

130

II618

In the past 7 days, It was hard to adjust to unexpected changes never

rarely

sometimes often

always

131

II619

In the past 7 days, Just being around people irritated me

never

rarely

sometimes often

always

132

II620

In the past 7 days, I felt people were trying to anger me

never

rarely

sometimes often

always

133

II621

In the past 7 days, I was irritated more than people knew

never

rarely

sometimes often

always

134

II622

never

rarely

sometimes often

always

135

never

rarely

sometimes often

always

136

II624

In the past 7 days, I was irritable around other people
In the past 7 days, People told me that I talked in a loud or
excessive manner
In the past 7 days, I said or did things that other people
probably thought were inappropriate

never

rarely

sometimes often

always

137

II284

In the past 7 days, I was resentful when I didn't get my way

never

rarely

sometimes often

always

138

II608
II609
II419
II611

II623

II625
II306
II626

In the past 7 days, I had a hard time accepting criticism from
other people
never
In the past 7 days, I was bothered if I had to depend on others
for help
never
In the past 7 days, I look forward with enjoyment to upcoming
events
never

rarely

sometimes often

always

139

rarely

sometimes often

always

140

rarely

sometimes often

always

141

In the past 7 days, I can keep up with my family responsibilities
In the past 7 days, I am able to do all the family activities that I
want to do
In the past 7 days, I am able to do all the family activities that I
am expected to do
In the past 7 days, I am able to maintain my friendships as
much as I would like
In the past 7 days, I have to limit my regular activities with
friends

never

rarely

sometimes often

always

142

never

rarely

sometimes often

always

143

never

rarely

sometimes often

always

144

never

rarely

sometimes often

always

145

never

rarely

sometimes often

always

146

never

rarely

sometimes often

always

147

II633

In the past 7 days, I can keep up with my social commitments
In the past 7 days, I have to limit social activities outside my
home

never

rarely

sometimes often

always

148

II634

In the past 7 days, I have trouble keeping in touch with others never

rarely

sometimes often

always

149

II635

rarely

sometimes often

always

150

rarely

sometimes often

always

151

II637

In the past 7 days, I avoided public places or activities
never
In the past 7 days, I can keep up with my work responsibilities
(including work at home)
never
In the past 7 days, I am able to do all of my usual work
(including work at home)
never

rarely

sometimes often

always

152

II639

In the past 7 days, I have to do my work in shorter periods of
time than usual for me (including household work)

never

rarely

sometimes often

always

153

never

rarely

sometimes often

always

154

never

rarely

sometimes often

always

155

II627
II628
II629
II630
II631
II632

II636

II598
II610

In the past 7 days, I had crying spells
In the past 7 days, I threatened violence toward people or
property

Physical Function
Informatio
Item
Filter: answer this
Item
item
#
Response Scale
n screen
Entry Order
The following questions have to do with your ability to move around. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Yes,
Yes, with a Yes, with Yes, with a
Are you able to move from lying on your back to sitting on the without
lot of
some
lot of
Unable to I don't
PD076
edge of your bed?
difficulty
difficulty
difficulty
difficulty
do
know
1
Yes,
Yes, with a Yes, with Yes, with a
Are you able to get moving after you've been lying down on a without
lot of
some
lot of
Unable to I don't
PD436
couch?
difficulty
difficulty
difficulty
difficulty
do
know
2
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD082
Are you able to get in and out of bed?
difficulty
difficulty
difficulty
difficulty
do
know
3
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD017
Are you able to get up off the floor from lying on your back?
difficulty
difficulty
difficulty
difficulty
do
know
4

PD529

Yes,
without
Are you able to get down on the floor?
difficulty
Yes,
without
Are you able to lie on the floor for 30 minutes?
difficulty
Yes,
Are you able to move around on your hands and knees in a
without
crawling position?
difficulty
Yes,
Are you able to work at floor level (e.g. changing the face plate without
on an electric outlet)?
difficulty
Yes,
without
Are you able to get in and out of a squatting position?
difficulty
Yes,
without
Are you able to get into and out of a kneeling position?
difficulty
Yes,
Are you able to kneel on the floor for a long time (e.g., when without
cleaning the bathtub or playing with kids or pets)?
difficulty
Yes,
without
Are you able to turn your head to look behind you?
difficulty

PD455

How long are you able to kneel?

PD437

PD090

PD178

PD452
PD438/PD443
9

PD440/PD441

PD454

Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty

Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty

Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty

30 minutes 20 minutes 10 minutes 2 minutes

Unable to
do

I don't
know

5

Unable to
do

I don't
know

6

Unable to
do

I don't
know

7

Unable to
do

I don't
know

8

Unable to
do

I don't
know

9

Unable to
do

I don't
know

10

Unable to
do

I don't
know

11

Unable to
do
unable to
do
Unable to
do

I don't
know
I don't
know
I don't
know

12
13

PD453
How long are you able to squat?
30 minutes 20 minutes 10 minutes 2 minutes
14
Item
Filter: answer this
Item
item
#
Response Scale
The following questions have to do with your ability to sit and stand. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD106
Are you able to sit on a stool without back support?
difficulty
difficulty
difficulty
difficulty
do
know
15
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD046
Are you able to stand up from an armchair?
difficulty
difficulty
difficulty
difficulty
do
know
16
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD045
Are you able to stand up from an armless, straight chair?
difficulty
difficulty
difficulty
difficulty
do
know
17
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD447
Are you able to stand up from a low, soft couch?
difficulty
difficulty
difficulty
difficulty
do
know
18
How long are you able to sit in a chair with short breaks? (e.g. 6 hours or
up to an
Unable to I don't
PD444
bathroom breaks)
more
2-4 hours hour
do
know
19
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD456
1F2
Are you able to stay on your feet for at least 20 minutes?
difficulty
difficulty
difficulty
difficulty
do
know
20
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD125
1F2
Are you able to stand for one hour?
difficulty
difficulty
difficulty
difficulty
do
know
21
Yes,
Yes, with a Yes, with Yes, with a
Are you able to remain on your feet for 2 hours with short
without
lot of
some
lot of
Unable to I don't
PD457
1F2
breaks?
difficulty
difficulty
difficulty
difficulty
do
know
22

Yes,
Yes, with a Yes, with Yes, with a
Are you able to remain on your feet for 6 hours with short
without
lot of
some
lot of
Unable to I don't
PD515
1F2
breaks?
difficulty
difficulty
difficulty
difficulty
do
know
23
The following questions have to do with your ability to walk and run. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Yes,
Yes, with a Yes, with Yes, with a
Are you able to walk around one floor of your home without
without
lot of
some
lot of
Unable to I don't
PD465
1F2
tripping or losing your balance?
difficulty
difficulty
difficulty
difficulty
do
know
24
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD245/142
1F2
Are you able to walk for at least 15 minutes?
difficulty
difficulty
difficulty
difficulty
do
know
25
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD460
1F2
Are you able to walk for at least 30 minutes?
difficulty
difficulty
difficulty
difficulty
do
know
26
Yes,
Yes, with a Yes, with Yes, with a
Are you able to walk in a busy place (e.g., crowded store)
without
lot of
some
lot of
Unable to I don't
PD466
1F2
without losing your balance?
difficulty
difficulty
difficulty
difficulty
do
know
27
Yes,
Yes, with a Yes, with Yes, with a
Are you able to walk quickly indoors (e.g. to answer the
without
lot of
some
lot of
Unable to I don't
PD167
1F2
telephone or the front door)?
difficulty
difficulty
difficulty
difficulty
do
know
28
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD538
1F2
Are you able to walk 150 feet (45 meters) on flat ground?
difficulty
difficulty
difficulty
difficulty
do
know
29
Yes,
Yes, with a Yes, with Yes, with a
Are you able to walk on uneven surfaces (e.g., grass, dirt road without
lot of
some
lot of
Unable to I don't
PD159
1F2
or sidewalk)?
difficulty
difficulty
difficulty
difficulty
do
know
30
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD158
1F2
Are you able to walk up a steep slope (e.g., on a hill)?
difficulty
difficulty
difficulty
difficulty
do
know
31
Yes,
Yes, with a Yes, with Yes, with a
Are you able to cross the road at a 4-lane traffic light with
without
lot of
some
lot of
Unable to I don't
PD461
1F2
curbs?
difficulty
difficulty
difficulty
difficulty
do
know
32
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD151
1F2
Are you able to walk a mile without resting?
difficulty
difficulty
difficulty
difficulty
do
know
33
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD209
Are you able to run a short distance, such as to catch a bus?
difficulty
difficulty
difficulty
difficulty
do
know
34
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD512
Are you able to run fast for 2 minutes?
difficulty
difficulty
difficulty
difficulty
do
know
35
More than
Unable to I don't
PD458
1F2
How long are you able to walk without stopping?
an hour
An hour
30 minutes 15 minutes do
know
36
At a normal
pace
At a slower
Faster than compared pace than
those
to those
those
Unable to I don't
PD459
How fast are you able to walk?
around me around me around me do
know
37
The following questions have to do with getting in and out of cars and buses. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD005PD006 Are you able to get into and out of a car?
difficulty
difficulty
difficulty
difficulty
do
know
38

Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD434/435
1F2
Are you able to step on and off a bus?
difficulty
difficulty
difficulty
difficulty
do
know
The following questions are about stairs and ladders. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD201
Are you able to go up one flight of stairs with a handrail?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD499
Are you able to go down one flight of stairs with a handrail?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD463
Are you able to go up one flight of stairs without a handrail?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD184
Are you able to go up three flights of stairs using a handrail? difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD464
Are you able to go up three flights of stairs without a handrail? difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD394
Are you able to carry a laundry basket up a flight of stairs?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD462
Are you able to climb 2 or 3 steps up a step ladder?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
Are you able to climb an extension ladder up the side of a
without
lot of
some
lot of
Unable to I don't
PD517
building?
difficulty
difficulty
difficulty
difficulty
do
know
The following questions are about using your hands. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
less than 2 Unable to I don't
PD522
How long are you able to use a computer mouse?
6 hours
4 hours
2 hours
hours
do
know
less than 2 Unable to I don't
PD469
How long are you able to use a computer keyboard?
6 hours
4 hours
2 hours
hours
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD468
Are you able to pick up coins from a table top?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD270
PD272
Are you able to pick up and put down a pen or pencil?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD373
Are you able to hold a book while reading?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD290
Are you able to hold a full glass of water in one hand?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD298
Are you able to turn faucets on and off?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD281
Are you able to open previously opened jars?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD289
Are you able to open childproof medicine bottles or jars?
difficulty
difficulty
difficulty
difficulty
do
know

39

40

41

42

43

44

45

46

47

48
49

50

51

52

53

54

55

56

PD286

PD282

PD539

PD292

PD316

PD314

PD547

PD311

PD523

PD545

PD344

PD546

PD315

PD327

PD288

PD474

PD539

PD472

Yes,
without
Are you able to open a tight or new jar?
difficulty
Yes,
without
Are you able to open a can with a hand can opener?
difficulty
Yes,
without
Are you able to staple 2 sheets of paper together?
difficulty
Yes,
without
Are you able to cut a piece of paper with scissors?
difficulty
Yes,
without
Are you able to pick out a paper clip from group of clips?
difficulty
Yes,
without
Are you able to remove wrappings from small objects?
difficulty
Yes,
without
Are you able to tie a knot?
difficulty
Yes,
without
Are you able to address an envelope with a pen?
difficulty
Yes,
without
Are you able to write for 20 minutes?
difficulty
Yes,
without
Are you able to pull a pillow case off a pillow?
difficulty
Yes,
without
Are you able to remove something from your back pocket ?
difficulty
Yes,
without
Are you able to use a wrench to tighten a bolt?
difficulty
Yes,
without
Are you able to pick out one key from group of keys?
difficulty
Yes,
without
Are you able to turn a key in a door lock?
difficulty
Yes,
without
Are you able to use a lever handle to open a door?
difficulty
Yes,
without
Are you able to turn a door knob?
difficulty
Yes,
Are you able to buckle a strap (e.g. on a bicycle helmet, child's without
car seat, or backpack)?
difficulty
Yes,
without
Are you able to sew on a button?
difficulty

Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty

Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty

Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty

Unable to
do

I don't
know

57

Unable to
do

I don't
know

58

Unable to
do

I don't
know

59

Unable to
do

I don't
know

60

Unable to
do

I don't
know

61

Unable to
do

I don't
know

62

Unable to
do

I don't
know

63

Unable to
do

I don't
know

64

Unable to
do

I don't
know

65

Unable to
do

I don't
know

66

Unable to
do

I don't
know

67

Unable to
do

I don't
know

68

Unable to
do

I don't
know

69

Unable to
do

I don't
know

70

Unable to
do

I don't
know

71

Unable to
do

I don't
know

72

Unable to
do

I don't
know

73

Unable to
do

I don't
know

74

Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD525
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD328
Are you able to remove a gas cap from a car?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD330
Are you able to change the bulb in a table lamp?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD475
Are you able to tighten screws by hand with a screwdriver?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD276
Are you able to use a hammer to pound a nail?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
Are you able to reach for a can in a shoulder height shelf and without
lot of
some
lot of
Unable to I don't
PD526
place it on a table or counter?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
Are you able to work overhead for 20 minutes (e.g. organizing without
lot of
some
lot of
Unable to I don't
PD479
a high shelf in a closet)?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD502
Are you able to wash windows indoors?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD524
Are you able to tightly attach a hose to an outside faucet?
difficulty
difficulty
difficulty
difficulty
do
know
The following questions are about reaching. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Yes,
Yes, with a Yes, with Yes, with a
Are you able to pass a full serving dish to the person sitting
without
lot of
some
lot of
Unable to I don't
PD513
next to you?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
Are you able to pass a full serving dish to the person sitting
without
lot of
some
lot of
Unable to I don't
PD544
across the table from you?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD343
Are you able to reach behind you to get your seatbelt?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD476
Are you able to reach overhead into a high cupboard?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD477
Are you able to put a small object into a high cupboard?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD478
Are you able to reach into a low cupboard?
difficulty
difficulty
difficulty
difficulty
do
know
The following questions are about bending. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions
Yes,
Yes, with a Yes, with Yes, with a
Are you able to bend over from a sitting position to pick up an without
lot of
some
lot of
Unable to I don't
PD514
object you dropped on the floor?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
Are you able to bend over to pick up an object that is on a low without
lot of
some
lot of
Unable to I don't
PD451
coffee table?
difficulty
difficulty
difficulty
difficulty
do
know
Are you able to put batteries in a flashlight, or remote control
for your television?

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD448
Are you able to bend down to pick up clothing from the floor? difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
Are you able to bend over to pick up coins that are scattered without
lot of
some
lot of
Unable to I don't
PD450
on the floor?
difficulty
difficulty
difficulty
difficulty
do
know
The following questions are about push and pull activities. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD257
Are you able to pull open a heavy door?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD259
Are you able to push open a heavy door?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD263
Are you able to push a vacuum?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD467
Are you able to push a full grocery cart?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD542
Are you able to trim a tree with long handle saw?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
Are you able to pull a cord on a lawn mower, chain saw,
without
lot of
some
lot of
Unable to I don't
PD470
generator or boat motor?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
Are you able to do yard work (e.g. plant shrubs or a garden) for without
lot of
some
lot of
Unable to I don't
PD519
2 hours?
difficulty
difficulty
difficulty
difficulty
do
know
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD265
Are you able to push a full wheelbarrow?
difficulty
difficulty
difficulty
difficulty
do
know
The following questions are about lifting items at different heights and weights. Please check the one response that describes your usual abilities. Some questions are very similar; please

PD530

Are you able to lift a full 2 liter soda bottle from the floor to
table height?

Yes,
without
difficulty

Yes, with a Yes, with
lot of
some
difficulty
difficulty

Yes, with a
lot of
Unable to
difficulty
do

I don't
know

PD488

Are you able to lift a gallon of milk from the floor to table
height?

Yes,
without
difficulty

Yes, with a Yes, with
lot of
some
difficulty
difficulty

Yes, with a
lot of
Unable to
difficulty
do

I don't
know

PD532

Yes,
Are you able to lift a full small (carry-on size) suitcase from the without
floor to table height?
difficulty

Yes, with a Yes, with
lot of
some
difficulty
difficulty

Yes, with a
lot of
Unable to
difficulty
do

I don't
know

2 liter soda
bottle= 3.5
lbs/1.5 kg
a gallon of
milk = 8.5
lbs./4 kg.
a small
carry-on
size
suitcase=
20 lbs./8
kg.

92

93

94

95

96

97

98

99

100

101

102

103

104

a full large
check-in
size
suitcase=
Yes,
Yes, with a Yes, with Yes, with a
40-50
Are you able to lift a full large (check-in size) suitcase from the without
lot of
some
lot of
Unable to I don't
lbs./18-23
PD534
floor to table height?
difficulty
difficulty
difficulty
difficulty
do
know
kg.
The following questions are about lifting items at different heights and weights. Please check the one response that describes your usual abilities. Some questions are very similar; please

PD505

Yes,
Are you able to lift a full 2 liter soda bottle from table height to without
a high shelf?
difficulty

Yes, with a Yes, with
lot of
some
difficulty
difficulty

Yes, with a
lot of
Unable to
difficulty
do

I don't
know

PD510

Are you able to lift a gallon of milk from table height to a high
shelf in fridge?

Yes,
without
difficulty

Yes, with a Yes, with
lot of
some
difficulty
difficulty

Yes, with a
lot of
Unable to
difficulty
do

I don't
know

PD533

Are you able to lift a full small (carry-on size) suitcase from
table height to a high shelf?

Yes,
without
difficulty

Yes, with a Yes, with
lot of
some
difficulty
difficulty

Yes, with a
lot of
Unable to
difficulty
do

I don't
know

2 liter soda
bottle= 3.5
lbs/1.5 kg
a gallon of
milk = 8.5
lbs./4 kg.
a small
carry-on
size
suitcase=
20 lbs./8
kg.

105

106

107

108

a full large
check-in
size
suitcase=
Yes,
Yes, with a Yes, with Yes, with a
40-50
Are you able to lift a full large (check-in size) suitcase from
without
lot of
some
lot of
Unable to I don't
lbs./18-23
PD535
table height to a high shelf?
difficulty
difficulty
difficulty
difficulty
do
know
kg.
109
The following questions are about carrying items for 30 feet. Please check the one response that describes your usual abilities. Some questions are very similar; please answer all questions.
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD495
Are you able to carry a full plastic shopping bag for 30 feet?
difficulty
difficulty
difficulty
difficulty
do
know
110
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD497
Are you able to carry a full paper grocery bag for 30 feet?
difficulty
difficulty
difficulty
difficulty
do
know
111
Yes,
Yes, with a Yes, with Yes, with a
without
lot of
some
lot of
Unable to I don't
PD496
Are you able to carry a full laundry basket for 30 feet?
difficulty
difficulty
difficulty
difficulty
do
know
112
a small
carry-on
size
Yes,
Yes, with a Yes, with Yes, with a
suitcase=
Are you able to carry a full small (carry-on size) suitcase for 30 without
lot of
some
lot of
Unable to I don't
20 lbs./8
PD533
feet?
difficulty
difficulty
difficulty
difficulty
do
know
kg.
113

PD537

PD354

Yes,
Are you able to carry a full large (check-in size) suitcase for 30 without
feet?
difficulty
Yes,
Are you able to pick up a kitchen chair and move it, in order to without
clean?
difficulty

Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty

Yes, with
some
difficulty
Yes, with
some
difficulty

Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty

Unable to
do

I don't
know

Unable to
do

I don't
know

a full large
check-in
size
suitcase=
40-50
lbs./18-23
kg.

114

115

Walking Aid
Short Question
Answers
You indicated that you use a walking aid (e.g., cane, crutches, or walker). The following questions
ask about your ability to do different standing and walking activities and if you normally use your walking aid to do the activity.
"Yes=","No
PD125
Do you normally use your walking aid to stand for one hour? =",
"Yes,
without
difficulty=",
"Yes, with a
PD125
Are you able to stand for one hour?
little
1F2

1F2

1F2

1F2

1F2

PD457

Do you normally use your walking aid to remain on your feet
for 2 hours with short breaks?

Yes=,"No="
,
"Yes,
without
difficulty=",
"Yes, with a
little

PD457

Are you able to remain on your feet for 2 hours with short
breaks?

PD515

Do you normally use your walking aid to remain on your feet
for 6 hours with short breaks?

PD515

Are you able to remain on your feet for 6 hours with short
breaks?

PD458

Do you normally use your walking aid when you know you
won’t be able to stop and take breaks?

PD458

How long are you able to walk without stopping?

PD459

Do you normally use your walking aid to walk fast?

PD459

How fast are you able to walk?

Yes=,"No="
,
"Faster
than those
around
me=","At a

PD538

Do you normally use your walking aid to walk 150 feet (45
meters) on flat ground?

Yes=,"No="
,

Yes=,"No="
,
"Yes,
without
difficulty=",
"Yes, with a
little
Yes=,"No="
,
"More than
an
hour=","An

1F2

1F2

1F2

1F2

PD538

Are you able to walk 150 feet (45 meters) on flat ground?

PD245/142

Do you normally use your walking aid to walk for at least 15
minutes?

PD245/142

Are you able to walk for at least 15 minutes?

PD151

Do you normally use your walking aid to walk a mile without
resting?

PD151

Are you able to walk a mile without resting?

PD460

Do you normally use your walking aid to walk for at least 30
minutes?

PD460

Are you able to walk for at least 30 minutes?

1F2

Yes=,"No="
,
"Yes,
without
difficulty=",
"Yes, with a
little
Yes=,"No="
,
"Yes,
without
difficulty=",
"Yes, with a
little
Yes=,"No="
,
"Yes,
without
difficulty=",
"Yes, with a
little

PD158

Do you normally use your walking aid to walk up a steep slope Yes=,"No="
(e.g., on a hill)?
,
"Yes,
without
difficulty=",
"Yes, with a
Are you able to walk up a steep slope (e.g., on a hill)?
little

PD159

Do you normally use your walking aid to walk on uneven
surfaces (e.g., grass, dirt road or sidewalk)?

PD159

Are you able to walk on uneven surfaces (e.g., grass, dirt road
or sidewalk)?

Yes=,"No="
,
"Yes,
without
difficulty=",
"Yes, with a
little

PD167

Do you normally use your walking aid to walk quickly indoors
(e.g. to answer the telephone or the front door)?

Yes=,"No="
,

PD158

1F2

"Yes,
without
difficulty=",
"Yes, with a
little

1F2

PD167

PD465

Do you normally use your walking aid to walk around one floor Yes=,"No="
of your home without tripping or losing your balance?
,
"Yes,
without
difficulty=",
Are you able to walk around one floor of your home without
"Yes, with a
tripping or losing your balance?
little

PD466

Do you normally use your walking aid to walk in a busy place
(e.g., crowded store) without losing your balance?

PD466

Are you able to walk in a busy place (e.g., crowded store)
without losing your balance?

PD465

1F2

1F2

PD461

1F2

PD461
PD434/435

1F2

Are you able to walk quickly indoors (e.g., to answer the
telephone or the front door)?

"Yes,
without
difficulty=",
"Yes, with a
little

PD434/435

Yes=,"No="
,
"Yes,
without
difficulty=",
"Yes, with a
little

Do you normally use your walking aid to cross the road at a 4- Yes=,"No="
lane traffic light with curbs?
,
"Yes,
without
difficulty=",
Are you able to cross the road at a 4-lane traffic light with
"Yes, with a
curbs?
little
Yes=,"No="
Do you normally use your walking aid to step on and off a bus? ,
"Yes,
without
difficulty=",
"Yes, with a
Are you able to step on and off a bus?
little

Wheelchair
Item
Item#
We are now going to ask you some questions about your ability to move around in your wheelchair.
Yes,
without
1F1
PD566
Are you able to get in and out of your wheelchair?
difficulty
Yes,
Are you able to move around one floor of your home in your without
1F1
PD543
wheelchair without bumping into things?
difficulty
Yes,
Are you able to move around in the bathroom, including
without
PD508
1F1
getting on and off the toilet from a wheelchair?
difficulty
Yes,
without
1F1
PD552
Are you able to move your wheelchair up and down curbs?
difficulty

Entry Order
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty

Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty

Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty

Unable to
do

I don't
know

116

Unable to
do

I don't
know

117

Unable to
do

I don't
know

118

Unable to
do

I don't
know

119

1F1

PD228

1F1

PD549

1F1

PD232

1F1

PD248

Yes,
without
Are you able to move a wheelchair for at least 15 minutes?
difficulty
Yes,
without
Are you able to cross the street at a traffic light in your wheelchair?
difficulty
Yes,
without
Are you able to get in and out of a car from a wheelchair?
difficulty
Yes,
Are you able to get into and out of a truck, bus, shuttle van, or without
sport utility vehicle from a wheelchair?
difficulty

Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty

Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty
Yes, with
some
difficulty

Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty
Yes, with a
lot of
difficulty

Unable to
do

I don't
know

120

Unable to
do

I don't
know

121

Unable to
do

I don't
know

122

Unable to
do

I don't
know

123