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?

Taking care of your household responsibilities?

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

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

Have you been emotionally affected by your health problems?

Concentrating on doing something for ten minutes?

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

Washing your whole body?

Getting dressed?

Dealing with people you do not know?

Maintaining a friendship?

Your day-to-day work?

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