Welcome to this survey. Press Next to begin.

Please answer the following questions using the following scale:

• None
• Mild
• Moderate
• Severe
• Extreme or cannot do

In the past 30 days, how much difficulty did you have in performing the following actions?

Standing for long periods such as 30 minutes?

None Mild Moderate Severe Extreme or cannot do

Taking care of your household responsibilities?

None Mild Moderate Severe Extreme or cannot do

Learning a new task, for example, learning how to get to a new place?

None Mild Moderate Severe Extreme or cannot do

Joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?

None Mild Moderate Severe Extreme or cannot do

Have you been emotionally affected by your health problems?

None Mild Moderate Severe Extreme or cannot do

Concentrating on doing something for ten minutes?

None Mild Moderate Severe Extreme or cannot do

Walking a long distance such as a kilometer or half a mile?

None Mild Moderate Severe Extreme or cannot do

Washing your whole body?

None Mild Moderate Severe Extreme or cannot do

Getting dressed?

None Mild Moderate Severe Extreme or cannot do

Dealing with people you do not know?

None Mild Moderate Severe Extreme or cannot do

Maintaining a friendship?

None Mild Moderate Severe Extreme or cannot do

Your day-to-day work?

None Mild Moderate Severe Extreme or cannot do

Congratulations for completing this survey! Press finish to continue.