Don't
know/
refused
(GO TO
NEXT TASK)
B
How much difficulty
do you
have...?
1 Some
2 A
lot
3 Unable to
do by
myself
8 Don't
know
C
Do you need any
assistive devices to
....., including
(READ RESPONSES
BELOW)
0 No
1 Glasses,
contacts
2 Hearing
aids
3 Special
devices
(tongs,
rubber
grips,
etc.)
4 Changes
in your
home or
car
(ramps,
rails,
elevator,
hand
gears,
etc.)
5 Cane,
walker,
braces
6 Wheelchair
7 Other
D
Do you need the
help of another
person to
.....?
0 No
1 Yes,
supervision,
someone
to stand
by
2 Yes, a
little help
(subject
75%)
3 Yes, a
moderate
amount
of help
(subject
50%)
4 Yes, a
lot of
help
(subject
25%)
5 Yes,
another
person
does it
completely for me
(subject
0%)
8 Don't
know
E
Have you modified
(changed) the way
you (--) in order to
continue to do it
successfully?
0 No (GO
TO
G)
1 Yes,
changed the
way I
do it
for
health
reasons
(GO
TO
F)
2 Yes,
changed the
way I
do it
for
non-health
reasons
(GO
TO
G)
8 Don't
know
F (SEE
BOTTOM OF
PAGE)
G
Have you changed
how frequently you
...?
0 No (IF NO TO A
AND E AND G, GO
TO NEXT
TASK)
1 Yes, cut back
2 Yes, given up
3 Yes, do it more
frequently
8 Don't
know
H (SEE BOTTOM OF
PAGE)
I
For how long have
you modified or had
difficulty or been
unable to do this
activity?
(LATTER TAKES
PRECEDENCE)
(ROUND TO
NEAREST YEAR OR)
ó 6 months = 00
ò 6 months = 01
Don't know = 88
J
What are the main
symptoms that
cause you to
modify, have
difficulty or prevent
you from doing the
activity?
(SEE CARD 1)
(CODE PRIMARY
REASON FIRST)
K
What are the main
conditions that
cause you to
modify, have
difficulty or prevent
you from doing the
activity?
(SEE CARD 2)
(CODE PRIMARY
REASON FIRST)
Do you have any
difficulty
8. ...walking half a
mile,
about 5-6
blocks?
GO TO Q20 IF MEET
AGE
CONDITIONS
9. (SKIP TO
11 IF NO
TO 8A)
...walking 150',
about
1/3
block?
10. ...walking around
your
home?
11. ...
bathing
or
showering?
(getting
in and
out of
tub,
standing
in
shower,
reaching
parts of
body ?)
*
A
CIRCLE CORRECT
ANSWER
0 1 2 3 4
8
0 1 2 3 4
8
0 1 2 3 4
8
0 1 2 3 4
8
B
____
____
____
____
8 Don't
know
C
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
D
____
____
____
____
E
____
____
____
____
G
____
____
____
____
I
____
____
____
____
J
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
K
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
F
IF YES TO E: How have you 8.
modified or changed the way
you do (--)? (different 9.
methods, clothes, etc.)
(GO TO G) 10.
H
IF 2 TO A AND * TASK 11.
How do you (--)? (SEE CARD 3) (GO TO I)
<---------------------------- IF YES TO A
---------------------------->
<------ IF 0
OR 1 TO A ------>
<----- IF YES OR DON'T DO TO A OR YES TO E OR
G ----->
A
Do you
have...?
0 No (GO
TO
E)
1 Yes (GO
TO B)
2 No
longer
do the
task due
to
difficulty
doing it
(GO TO
H)
3 Could
do it but
don't for
non-
health
reasons
(GO TO
I)
4 Never
did it
(GO TO
J)
8 Don't
know/
refused
(GO TO
NEXT TASK)
B
How much difficulty
do you
have...?
1 Some
2 A lot
3 Unable to do
by
myself
8 Don't
know
C
Do you need any
assistive devices to
....., including
(READ RESPONSES
BELOW)
0 No
1 Glasses,
contacts
2 Hearing
aids
3 Special
devices
(tongs,
rubber
grips,
etc.)
4 Changes
in your
home or
car
(ramps,
rails,
elevator,
hand
gears,
etc.)
5 Cane,
walker,
braces
6 Wheelchair
7 Other
8 Don't
know
D
Do you need the
help of another
person to
.....?
0 No
1 Yes,
supervision,
someone
to stand
by
2 Yes, a
little help
(subject
75%)
3 Yes, a
moderate
amount
of help
(subject
50%)
4 Yes, a
lot of
help
(subject
25%)
5 Yes,
another
person
does it
completely for me
(subject
0%)
8 Don't
know
E
Have you modified
(changed) the way
you (--) in order to
continue to do it
successfully?
0 No (GO
TO
G)
1 Yes,
changed the
way I
do it
for
health
reasons
(GO
TO
F)
2 Yes,
changed the
way I
do it
for
non-health
reasons
(GO
TO
G)
8 Don't
know
F (SEE
BOTTOM OF
PAGE)
G
Have you changed
how frequently you
...?
0 No (IF NO TO A
AND E AND G, GO
TO NEXT
TASK)
1 Yes, cut back
2 Yes, given up
3 Yes, do it more
frequently
8 Don't
know
H (SEE BOTTOM OF
PAGE)
I
For how long have
you modified or had
difficulty or been
unable to do this
activity?
(LATTER TAKES
PRECEDENCE)
(ROUND TO
NEAREST YEAR OR)
< 6 months = 00
6 - 12 months = 01
Don't know = 88
J
What are the main
symptoms that
cause you to
modify, have
difficulty or prevent
you from doing the
activity?
(SEE CARD ONE)
(CODE PRIMARY
REASON FIRST)
K
What are the main
conditions that
cause you to
modify, have
difficulty or prevent
you from doing the
activity?
(SEE CARD TWO)
(CODE PRIMARY
REASON FIRST)
Do you have any
difficulty
12. ...dressing
yourself?
(Do you
have
trouble
with
buttons,
fasteners,
zippers?)
*
13. ...preparing your
own
meals?
*
14. ...using
the
toilet,
including
getting
to and
from the
toilet?*
15. ...using
the
telephone?
*
A
CIRCLE CORRECT
ANSWER
0 1 2 3 4
8
0 1 2 3 4
8
0 1 2 3 4
8
0 1 2 3 4
8
B
____
____
____
____
C
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
D
____
____
____
____
E
____
____
____
____
G
____
____
____
____
I
____
____
____
____
J
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
K
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
F
IF YES TO E: How have you 12.
modified or changed the way
you do (--)? (different 13.
methods, clothes, etc.)
(GO TO G) 14.
H
IF 2 TO A AND * TASK 15.
How do you (--)? (SEE CARD 3)
GO TO I <---------------------------- IF YES TO A
---------------------------->
<------ IF 0
OR 1 TO A ------>
<----- IF YES OR DON'T DO TO A OR YES TO E OR
G ----->
A
Do you
have...?
0 No (GO
TO
E)
1 Yes (GO
TO B)
2 No
longer
do the
task due
to
difficulty
doing it
(GO TO
H)
3 Could
do it but
don't for
non-
health
reasons
(GO TO
I)
4 Never
did it
(GO TO
J)
8 Don't
know/
refused
(GO TO
NEXT TASK)
B
How much difficulty
do you
have...?
1 Some
2 A lot
3 Unable to do
by
myself
8 Don't
know
C
Do you need any
assistive devices to
....., including
(READ RESPONSES
BELOW)
0 No
1 Glasses,
contacts
2 Hearing
aids
3 Special
devices
(tongs,
rubber
grips,
etc.)
4 Changes
in your
home or
car
(ramps,
rails,
elevator,
hand
gears,
etc.)
5 Cane,
walker,
braces
6 Wheelchair
7 Other
D
Do you need the
help of another
person to
.....?
0 No
1 Yes,
supervision,
someone
to stand
by
2 Yes, a
little help
(subject
75%)
3 Yes, a
moderate
amount
of help
(subject
50%)
4 Yes, a
lot of
help
(subject
25%)
5 Yes,
another
person
does it
completely for me
(subject
0%)
8 Don't
know
E
Have you modified
(changed) the way
you (--) in order to
continue to do it
successfully?
0 No (GO
TO
G)
1 Yes,
changed the
way I
do it
for
health
reasons
(GO
TO
F)
2 Yes,
changed the
way I
do it
for
non-health
reasons
(GO
TO
G)
8 Don't
know
F
(SEE
BOTTOM OF
PAGE)
G
Have you changed
how frequently you
...?
0 No (IF NO TO A
AND E AND G, GO
TO NEXT TASK)
1 Yes, cut back
2 Yes, given up
3 Yes, do it more
frequently
8 Don't know
H (SEE BOTTOM OF
PAGE)
I
For how long have
you modified or had
difficulty or been
unable to do this
activity?
(LATTER TAKES
PRECEDENCE)
(ROUND TO
NEAREST YEAR OR)
< 6 months = 00
6 - 12 months = 01
Don't know = 88
J
What are the main
symptoms that
cause you to
modify, have
difficulty or prevent
you from doing the
activity?
(SEE CARD ONE)
(CODE PRIMARY
REASON FIRST)
K
What are the main
conditions that
cause you to
modify, have
difficulty or prevent
you from doing the
activity?
(SEE CARD TWO)
(CODE PRIMARY
REASON FIRST)
Do you have any
difficulty
16. ...getting
to places
out of
walking
distance?
*
17. ...shopping for
personal
items?
*
18. ...giving
yourself
medications?
*
19. ...managing your
own
money,
such as
paying
bills?
*
A
CIRCLE CORRECT
ANSWER
0 1 2 3 4
8
0 1 2 3 4
8
0 1 2 3 4
8
0 1 2 3 4
8
B
____
____
____
____
8 Don't
know
C
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
D
____
____
____
____
E
____
____
____
____
G
____
____
____
____
I
____
____
____
____
J
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
K
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
____ ____
F
IF YES TO E: How have you 16.
modified or changed the way
you do (--)? (different 17.
methods, clothes, etc.)
(GO TO G) 18.
H
IF 2 TO A AND * TASK 19.
How do you (--)? (SEE CARD 3)
(GO TO I)
<---------------------------- IF YES TO A ---------------------------->
<------ IF 0 OR 1 TO A ------>
<----- IF YES OR DON'T DO TO A OR
YES TO E OR G ----->
A
Do you
have...?
0 No (GO
TO
E)
1 Yes (GO
TO B)
2 No
longer
do the
task due
to
difficulty
doing it
(GO TO
H)
3 Could
do it but
don't for
non-
health
reasons
(GO TO
I)
4 Never
did it
(GO TO
J)
8 Don't
know/
refused
(GO TO
NEXT TASK)
B
How much difficulty
do you
have...?
1 Some
2 A lot
3 Unable to
do by
myself
8 Don't
know
C
Do you need any
assistive devices to
....., including
(READ RESPONSES
BELOW)
0 No
1 Glasses,
contacts
2 Hearing
aids
3 Special
devices
(tongs,
rubber
grips,
etc.)
4 Changes
in your
home or
car
(ramps,
rails,
elevator,
hand
gears,
etc.)
5 Cane,
walker,
braces
6 Wheelchair
7 Other
D
Do you need the
help of another
person to
.....?
0 No
1 Yes,
supervision,
someone
to stand
by
2 Yes, a
little help
(subject
75%)
3 Yes, a
moderate
amount
of help
(subject
50%)
4 Yes, a
lot of
help
(subject
25%)
5 Yes,
another
person
does it
completely for me
(subject
0%)
8 Don't
know
E
Have you modified
(changed) the way
you (--) in order to
continue to do it
successfully?
0 No (GO
TO
G)
1 Yes,
changed the
way I
do it
for
health
reasons
(GO
TO
F)
2 Yes,
changed the
way I
do it
for
non-health
reasons
(GO
TO
G)
8 Don't
know
F (SEE
BOTTOM OF
PAGE)
G
Have you changed
how frequently you
...?
0 No (IF NO TO A
AND E AND G, GO
TO NEXT
TASK)
1 Yes, cut back
2 Yes, given up
3 Yes, do it more
frequently
8 Don't know
H
(SEE BOTTOM OF
PAGE)
I
For how long have
you modified or had
difficulty or been
unable to do this
activity?
(LATTER TAKES
PRECEDENCE)
(ROUND TO
NEAREST YEAR OR)
< 6 months = 00
6 - 12 months = 01
Don't know = 88
J
What are the main
symptoms that
cause you to
modify, have
difficulty or prevent
you from doing the
activity?
(SEE CARD ONE)
(CODE PRIMARY
REASON FIRST)
K
What are the main
conditions that
cause you to
modify, have
difficulty or prevent
you from doing the
activity?
(SEE CARD TWO)
(CODE PRIMARY
REASON FIRST)
20. Have
you ever
done
physical
activities
comparable to
strenuous ones
such as
racquetball,
jogging,
heavy
construction
work,
swimming, or
aerobic
exercise?
21. Do you
currently
have any
difficulty
doing
these or
comparable
activity(ies)?
A
CIRCLE CORRECT
ANSWER
NO
(CIRCLE 4 IN 21-A
AND GO TO
QUESTION 21-J)
YES
(GO TO QUESTION
21-A)
0 1 2 3 4 8
B
____
8 Don't
know
C
____
____
D
____
E
____
G
____
I
____
J
____ ____
____ ____
K
____ ____
____ ____
F
IF YES TO E: How have you 21.
modified or changed the way
you do (--)? (different
methods, clothes, etc.)
(GO TO G)
H
IF 2 TO A AND * TASK
How do you (--)? (SEE CARD 3)
(GO TO I)
<---------------------------- IF YES TO A ---------------------------->
<------ IF 0 OR 1 TO A ------>
<----- IF YES OR DON'T DO TO A OR
YES TO E OR G ----->
A
Do you
have...?
0 No (GO
TO
E)
1 Yes (GO
TO B)
2 No
longer
do the
task due
to
difficulty
doing it
(GO TO
H)
3 Could
do it but
don't for
non-
health
reasons
(GO TO
I)
4 Never
did it
(GO TO
J)
8 Don't
know/
refused
(GO TO
NEXT TASK)
B
How much difficulty
do you
have...?
1 Some
2 A lot
3 Unable to do
by myself
8 Don't know
C
Do you need any
assistive devices to
....., including
(READ RESPONSES
BELOW)
0 No
1 Glasses,
contacts
2 Hearing
aids
3 Special
devices
(tongs,
rubber
grips,
etc.)
4 Changes
in your
home or
car
(ramps,
rails,
elevator,
hand
gears,
etc.)
5 Cane,
walker,
braces
6 Wheelchair
7 Other
D
Do you need the
help of another
person to
.....?
0 No
1 Yes,
supervision,
someone
to stand
by
2 Yes, a
little help
(subject
75%)
3 Yes, a
moderate
amount
of help
(subject
50%)
4 Yes, a
lot of
help
(subject
25%)
5 Yes,
another
person
does it
completely for me
(subject
0%)
8 Don't
know
E
Have you modified
(changed) the way
you (--) in order to
continue to do it
successfully?
0 No (GO
TO
G)
1 Yes,
changed the
way I
do it
for
health
reasons
(GO
TO
F)
2 Yes,
changed the
way I
do it
for
non-health
reasons
(GO
TO
G)
8 Don't
know
F (SEE
BOTTOM OF
PAGE)
G
Have you changed
how frequently you
...?
0 No (IF NO TO A
AND E AND G, GO
TO NEXT
TASK)
1 Yes, cut back
2 Yes, given up
3 Yes, do it more
frequently
8 Don't know
H
(SEE BOTTOM OF
PAGE)
I
For how long have
you modified or had
difficulty or been
unable to do this
activity?
(LATTER TAKES
PRECEDENCE)
(ROUND TO
NEAREST YEAR OR)
< 6 months = 00
6 - 12 months = 01
Don't know = 88
J
What are the main
symptoms that
cause you to
modify, have
difficulty or prevent
you from doing the
activity?
(SEE CARD ONE)
(CODE PRIMARY
REASON FIRST)
K
What are the main
conditions that
cause you to
modify, have
difficulty or prevent
you from doing the
activity?
(SEE CARD TWO)
(CODE PRIMARY
REASON FIRST)
22. (SKIP TO
23 IF NO
TO 21A)
Do you
have any
difficulty
doing
activities
comparable to
moderate
ones
such as
golf,
bowling,
vacuuming, or
gardening?
23. What is
the most
strenuous activity
that you
do?
(FILL IN
ACTIVITY)
______________________________
Do you
have any
difficulty
doing
this
activity?
A
CIRCLE CORRECT
ANSWER
0 1 2 3 4
8
0 1 2 3 4
8
B
____
____
8 Don't
know
C
____
____
____
____
____
____
____
____
D
____
____
E
____
____
G
____
____
I
____
____
J
____ ____
____ ____
____ ____
____ ____
K
____ ____
____ ____
____ ____
____ ____
F
IF YES TO E: How have you 22.
modified or changed the way
you do (--)? (different 23.
methods, clothes, etc.)
(GO TO G)
H
IF 2 TO A AND * TASK
How do you (--)? (SEE CARD 3)
(GO TO I)
CARD 1
SYMPTOMS
1 Shortness of breath
2 Diminished cardiovascular function/reduced endurance
3 Diminished muscle tone/reduced strength
4 Chest pain/discomfort
5 Stiffness (Specify where )
6 Back pain
7 Calf pain with walking
8 Pain, other site (Specify where )
9 Fear of pain/avoiding pain
10 Light headedness/dizziness
11 Weakness/fatigue
12 Difficulty walking
13 Unsteady on feet
14 Afraid of falling
15 Difficulty seeing; in general
16 Difficulty seeing at night in dim lights
17 Difficulty seeing when there is glare
18 Difficulty hearing normal conversation
19 Difficulty hearing in a noisy room
20 Preventing a problem I am at risk for (Specify )
21 Other
22 Non-health reason (Specify )
77 No reason
88 Don't know
CARD 2
CONDITIONS
1 Heart disease
2 Atherosclerosis
3 Stroke
4 High blood pressure
5 Lung disease/breathing problems
6 Arthritis - hands, arms, shoulders (specify where by circling area)
7 Arthritis - hips, knees, feet (specify where by circling area)
8 Osteoporosis
9 Hip fracture
10 Hip replacement
11 Problem with back or neck
12 Paralysis
13 Eye disease
14 Cancer
15 Injury
16 Diabetes
17 Overweight
18 Incontinence
19 Memory problems
20 Mental illness
21 Old age
22 Other
23 Non-health reason (Specify )
77 No reason
88 Don't know
CARD 3
QUESTIONS TO BE ASKED FOR H
2. How do you get to places to which you used to drive?
3. How do you reach and get objects that are above your head?
4. How do you get things that are on the floor or low to the ground?
5. How do you get jars open (such as ketchup, plastic milk bottle lids)?
6. How does the housework get done?
7. How do you move something as heavy as 10 pounds?
11. How do you bathe (or shower)?
12. How do you get dressed?
13. How do you get your meals?
14. How do you use the toilet?
15. How do your calls get made?
16. How do you get to places out of walking distance?
17. How does your shopping get done?
18. How do you get your medications?
19. How is your money managed?
JM -
Disclaimer
Revised 12/09/98 -- Send comments to our
Web Master
.