pfi1.qst
.title=Initial Physical Functioning Inventory (PFI)
.instances=1
.hidden=true
****************************************************************
***** PFI SURVEY INSTRUMENT December 1999 (version PFI4.qst)
****************************************************************
.qu=voide1,type=void
PHYSICAL FUNCTIONING INVENTORY (PFI)
You will be asked a series of questions about whether you have difficulty doing specific activities in your daily life. You will also be asked whether you have changed the way that you do each activity so that you can continue to do it successfully. Please think about how you currently do each task and whether you are doing anything differently now compared to how you did it before.
Changes can include the use of assistive devices, like using a cane or a handrail, doing an activity more slowly, needing the help of another person, or any other change.
Some questions will require you to select one answer while others require you to select all answers that apply. Some questions will require you to type in your answer. After selecting or typing your answer, hit the "next" key to go to the next question. You may use the "back" key to return to a previous question. After every three questions you complete, your answers will be automatically saved. If you choose to complete part of the survey and finish the rest at a later time, hit "save and close" and when you return the survey will start again where you left off. Please contact Alexis Officer if you have any questions.
Thank You.
.an
PRESS "NEXT" TO CONTINUE
.next
.qu=E1a,type=select
Do you have any difficulty walking up 10 steps?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.bah
.if (E1a = 1) E1c
.if (E1a = 2) E1b
.if (E1a = 3) E1e
.if (E1a = 4) E2a
.if (E1a = 5) E2a
.if (E1a = 6) E1c
.next
.qu=E1b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty",
how much difficulty do you have walking up 10 steps?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E1c,type=select
Have you modified or changed the way you walk up 10 steps?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E1c = 2) E1d
.if ((E1a = 1 or E1a = 6) and (E1c = 1 or E1c = 3 or E1c = 4)) E2a
.lo=1
.hi=4
.next=E1e
.qu=E1d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you walk up 10 steps?
(CHECK ALL THAT APPLY)
.an
I take longer to walk up 10 steps
I am more careful or cautious when walking up 10 steps
I walk up steps less often
I use assistive devices (e.g., handrail, cane)
I've simplified the task (go up 1 step at a time,step up with same leg)
I need the help of anther person to walk up 10 steps
OTHER (specify)
.if (E1d = 0) E1dwarn
.if (E1d @ 7) E1dx
.next=E1e
.qu=E1dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E1d
.qu=E1dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E1e,type=number
For how long have you (changed or had difficulty
with or been unable to) walk up 10 steps?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E2a,type=select
Do you have any difficulty driving?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E2a = 1) E2c
.if (E2a = 2) E2b
.if (E2a = 3) E2e
.if (E2a = 4) E3a
.if (E2a = 5) E3a
.if (E2a = 6) E2c
.next
.qu=E2b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty",
how much difficulty do you have driving?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E2c,type=select
Have you modified or changed the way you drive?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E2c = 2) E2d
.if ((E2a = 1 or E2a = 6) and (E2c = 1 or E2c = 3 or E2c = 4)) E3a
.lo=1
.hi=4
.next=E2e
.qu=E2d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you drive?
(CHECK ALL THAT APPLY)
.an
I drive slower
I am more careful or cautious when driving
I drive less often
I use assistive devices while driving (special driving equipment)
I've simplified the task of driving (avoid driving at night)
I need the help of another person to drive
OTHER (specify)
.if (E2d = 0) E2dwarn
.if (E2d @ 7) E2dx
.next=E2e
.qu=E2dwarn,type=void
You did select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E2d
.qu=E2dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E2e,type=number
For how long have you
(changed or had difficulty with or been unable to) drive?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E3a,type=select
Do you have any difficulty reaching for and getting down
a five pound object (like a bag of sugar) from just above your head?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E3a = 1) E3c
.if (E3a = 2) E3b
.if (E3a = 3) E3e
.if (E3a = 4) E4a
.if (E3a = 5) E4a
.if (E3a = 6) E3c
.next
.qu=E3b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty",
how much difficulty do you have
reaching for and getting down a five pound object
(like a bag of sugar) from just above your head?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E3c,type=select
Have you modified or changed the way you
reach for and get down a five pound object
(like a bag of sugar) from just above your head?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E3c = 2) E3d
.if ((E3a = 1 or E3a = 6) and (E3c = 1 or E3c = 3 or E3c = 4)) E4a
.lo=1
.hi=4
.next=E3e
.qu=E3d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
reach for and get down a five pound object
(like a bag of sugar) from just above your head?
(CHECK ALL THAT APPLY)
.an
I am slower at getting an object down from above my head
I am more careful when getting something down from above my head
I get things down from above my head less often
I use assistive devices (cane, hold onto counter)
I've simplified the task (keep objects down low, use both arms)
I need the help of another person to get objects down
OTHER (specify)
.if (E3d = 0) E3dwarn
.if (E3d @ 7) E3dx
.next=E3e
.qu=E3dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E3d
.qu=E3dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E3e,type=number
For how long have you
(changed or had difficulty with or been unable to)
reach for and get down a five pound object
(like a bag of sugar) from just above your head?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E4a,type=select
Do you have any difficulty
stooping, crouching, or kneeling?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E4a = 1) E4c
.if (E4a = 2) E4b
.if (E4a = 3) E4e
.if (E4a = 4) E5a
.if (E4a = 5) E5a
.if (E4a = 6) E4c
.next
.qu=E4b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have stooping, crouching, or kneeling?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E4c,type=select
Have you modified or changed the way you
stoop, crouch, or kneel?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E4c = 2) E4d
.if ((E4a = 1 or E4a = 6) and (E4c = 1 or E4c = 3 or E4c = 4)) E5a
.lo=1
.hi=4
.next=E4e
.qu=E4d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
stoop, crouch, or kneel?
(CHECK ALL THAT APPLY)
.an
I am slower when I stoop, crouch, or kneel
I am more careful or cautious when stooping, crouching, or kneeling
I stoop, crouch, or kneel less often
I use assistive devices (furniture to hold onto, pinchers)
I've simplified the task (go down on strong leg, sit down to bend over)
I need the help of another person to stoop, crouch or kneel
OTHER (specify)
.if (E4d = 0) E4dwarn
.if (E4d @ 7) E4dx
.next=E4e
.qu=E4dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E4d
.qu=E4dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E4e,type=number
For how long have you (changed or had difficulty with
or been unable to) stoop, crouch, or kneel?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
************************************************************
.qu=E5a,type=select
Do you have any difficulty opening
jars that have already been opened?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E5a = 1) E5c
.if (E5a = 2) E5b
.if (E5a = 3) E5e
.if (E5a = 4) E6a
.if (E5a = 5) E6a
.if (E5a = 6) E5c
.next
.qu=E5b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have opening jars that have already been opened?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E5c,type=select
Have you modified or changed the way you
open jars that have already been opened?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E5c = 2) E5d
.if ((E5a = 1 or E5a = 6) and (E5c = 1 or E5c = 3 or E5c = 4)) E6a
.lo=1
.hi=4
.next=E5e
.qu=E5d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
open jars that have already been opened?
(CHECK ALL THAT APPLY)
.an
I am slower opening jars
I am more careful or cautious when opening jars
I open jars less often
I use assistive devices (e.g., rubber grip device)
I've simplified the task (use good hand, avoid screwing lid on tightly)
I need the help of another person to open jars
OTHER (specify)
.if (E5d = 0) E5dwarn
.if (E5d @ 7) E5dx
.next=E5e
.qu=E5dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E5d
.qu=E5dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E5e,type=number
For how long have you (changed or had difficulty
with or been unable to) open jars that have already been opened?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E6a,type=select
Do you have any difficulty doing light housework
(sweeping, straightening up, doing dishes)?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E6a = 1) E6c
.if (E6a = 2) E6b
.if (E6a = 3) E6e
.if (E6a = 4) E7a
.if (E6a = 5) E7a
.if (E6a = 6) E6c
.next
.qu=E6b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have doing light housework (sweeping, straightening up,
doing dishes)?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E6c,type=select
Have you modified or changed the way you do light housework
(sweeping, straightening up, doing dishes)?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E6c = 2) E6d
.if ((E6a = 1 or E6a = 6) and (E6c = 1 or E6c = 3 or E6c = 4)) E7a
.lo=1
.hi=4
.next=E6e
.qu=E6d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
do light housework (sweeping, straightening up, doing dishes)?
(CHECK ALL THAT APPLY)
.an
I do light housework more slowly
I am more careful or cautious when doing light housework
I do light housework less often
I use assistive devices (e.g., cane)
I've simplified the task (no longer vacuum, do less work at a one time)
I need the help of another person to do light household work
OTHER (specify)
.if (E6d = 0) E6dwarn
.if (E6d @ 7) E6dx
.next=E6e
.qu=E6dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E6d
.qu=E6dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E6e,type=number
For how long have you (changed or had difficulty
with or been unable to) do light housework
(sweeping, straightening up, doing dishes)?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E7a,type=select
Do you have any difficulty lifting or carrying something
as heavy as ten pounds like a full bag of groceries?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E7a = 1) E7c
.if (E7a = 2) E7b
.if (E7a = 3) E7e
.if (E7a = 4) E8a
.if (E7a = 5) E8a
.if (E7a = 6) E7c
.next
.qu=E7b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty",
how much difficulty do you have
lifting or carrying something as heavy as ten pounds
like a full bag of groceries?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E7c,type=select
Have you modified or changed the way you
lift or carry something as heavy as ten pounds
like a full bag of groceries?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E7c = 2) E7d
.if ((E7a = 1 or E7a = 6) and (E7c = 1 or E7c = 3 or E7c = 4)) E8a
.lo=1
.hi=4
.next=E7e
.qu=E7d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
lift or carry something as heavy as ten pounds
like a full bag of groceries?
(CHECK ALL THAT APPLY)
.an
I am slower when I lift or carry an object
I am more careful or cautious when lifting or carrying an object
I lift or carry an object less often
I use assistive devices (e.g., cart, cane, walker)
I've simplified the task (e.g., use both hands, cane, drag the object)
I need the help of another person to lift or carry something
OTHER (specify)
.if (E7d = 0) E7dwarn
.if (E7d @ 7) E7dx
.next=E7e
.qu=E7dwarn,type=void
You did not select any responses.
Press the enter key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E7d
.qu=E7dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E7e,type=number
For how long have you (changed or had difficulty with
or been unable to) lift or carry something as heavy as
ten pounds like a full bag of groceries?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E8a,type=select
Do you have any difficulty
walking 1/2 mile, about 5 or 6 blocks?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E8a = 1) E8c
.if (E8a = 2) E8b
.if (E8a = 3) E8e
.if (E8a = 4) E9a
.if (E8a = 5) E9a
.if (E8a = 6) E8c
.next
.qu=E8b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have walking 1/2 mile, about 5 or 6 blocks?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E8c,type=select
Have you modified or changed the way you
walk 1/2 mile, about 5 or 6 blocks?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E8c = 2) E8d
.if ((E8a = 1 or E8a = 6) and (E8c = 1 or E8c = 3 or E8c = 4)) E9a
.lo=1
.hi=4
.next=E8e
.qu=E8d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
walk 1/2 mile, about 5 or 6 blocks?
(CHECK ALL THAT APPLY)
.an
I am slower when I walk 1/2 mile
I am more careful or cautious when walking 1/2 mile
I walk 1/2 mile less often
I use assistive devices to walk 1/2 mile (e.g., cane, walker)
I've simplified the task (take smaller steps, take rests, favor 1 leg)
Need the help of another person to walk 1/2 mile
OTHER (specify)
.if (E8d = 0) E8dwarn
.if (E8d @ 7) E8dx
.next=E8e
.qu=E8dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E8d
.qu=E8dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E8e,type=number
For how long have you (changed or had difficulty with
or been unable to) walk 1/2 mile, about 5 or 6 blocks?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E9a,type=select
Do you have any difficulty
walking 150 feet, about 1/3 of a block?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E9a = 1) E9c
.if (E9a = 2) E9b
.if (E9a = 3) E9e
.if (E9a = 4) E10a
.if (E9a = 5) E10a
.if (E9a = 6) E9c
.next
.qu=E9b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty",
how much difficulty do you have
walking 150 feet, about 1/3 of a block?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E9c,type=select
Have you modified or changed the way you
walk 150 feet, about 1/3 of a block?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E9c = 2) E9d
.if ((E9a = 1 or E9a = 6) and (E9c = 1 or E9c = 3 or E9c = 4)) E11a
.lo=1
.hi=4
.next=E9e
.qu=E9d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
walk 150 feet, about 1/3 of a block?
(CHECK ALL THAT APPLY)
.an
I am slower when I walk 1/3 block
I am more careful or cautious when walking 1/3 mile
I walk 1/3 mile less often
I use assistive devices (e.g., cane, walker)
I've simplified the task (take smaller steps, take rests, favor 1 leg)
I need the help of another person
OTHER (specify)
.if (E9d = 0) E9dwarn
.if (E9d @ 7) E9dx
.next=E9e
.qu=E9dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E1d
.qu=E9dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E9e,type=number
For how long have you
(changed or had difficulty with or been unable to)
walk 150 feet, about 1/3 of a block?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E10a,type=select
Do you have any difficulty
walking around your home?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E10a = 1) E10c
.if (E10a = 2) E10b
.if (E10a = 3) E10e
.if (E10a = 4) E11a
.if (E10a = 5) E11a
.if (E10a = 6) E10c
.next
.qu=E10b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty",
how much difficulty do you have
walking around your home?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E10c,type=select
Have you modified or changed the way you
walk around your home?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E10c = 2) E10d
.if ((E10a = 1 or E10a = 6) and (E10c = 1 or E10c = 3 or E10c = 4)) E11a
.lo=1
.hi=4
.next=E10e
.qu=E10d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
walk around your home?
(CHECK ALL THAT APPLY)
.an
I am slower when I walk around my home
I am more careful or cautious when walking around my home
I walk around my home less often
I use assistive devices (cane, walker, handrail or furniture)
I've simplified the task (take smaller steps, take rests, favor 1 leg)
I need the help of another person to walk around my home
OTHER (specify)
.if (E10d = 0) E10dwarn
.if (E10d @ 7) E10dx
.next=E10e
.qu=E10dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E10d
.qu=E10dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E10e,type=number
For how long have you
(changed or had difficulty with or been unable to)
walk around your home?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E11a,type=select
Do you have any difficulty
with the way you bathe or shower
(get in and out of tub, stand in shower, reach parts of body)?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E11a = 1) E11c
.if (E11a = 2) E11b
.if (E11a = 3) E11e
.if (E11a = 4) E12a
.if (E11a = 5) E12a
.if (E11a = 6) E11c
.next
.qu=E11b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty",
how much difficulty do you have
with the way you bathe or shower
(get in and out of tub, stand in shower, reach parts of body)?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E11c,type=select
Have you modified or changed the way you
bathe or shower (get in and out of tub,
stand in shower, reach parts of body)?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E11c = 2) E11d
.if ((E11a = 1 or E11a = 6) and (E11c = 1 or E11c = 3 or E11c = 4)) E12a
.lo=1
.hi=4
.next=E11e
.qu=E11d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
bathe or shower (get in and out of tub,
stand in shower, reach parts of body)?
(CHECK ALL THAT APPLY)
.an
I bathe or shower more slowly
I am more careful or cautious when bathing
I bathe less often
I use assistive devices (shower seat, grab bars, hand held shower)
I've simplified the task (take sponge baths, take only showers)
I need the help of another person to bathe or shower
OTHER (specify)
.if (E11d = 0) E11dwarn
.if (E11d @ 7) E11dx
.next=E11e
.qu=E11dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E11d
.qu=E11dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E11e,type=number
For how long have you
(changed or had difficulty with or been unable to)
bathe or shower (get in and out of tub,
stand in shower, reach parts of body)?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E12a,type=select
Do you have any difficulty
with the way you dress yourself
(for example, trouble with buttons, fasteners, zippers)?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E12a = 1) E12c
.if (E12a = 2) E12b
.if (E12a = 3) E12e
.if (E12a = 4) E13a
.if (E12a = 5) E13a
.if (E12a = 6) E12c
.next
.qu=E12b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have with the way you dress yourself (for example, trouble
with buttons, fasteners, zippers)?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E12c,type=select
Have you modified or changed the way you dress yourself?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E12c = 2) E12d
.if ((E12a = 1 or E12a = 6) and (E12c = 1 or E12c = 3 or E12c = 4)) E13a
.lo=1
.hi=4
.next=E12e
.qu=E12d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
dress yourself?
(CHECK ALL THAT APPLY)
.an
I dress more slowly
I am more careful or cautious when dressing
I get dressed less often
I use assistive devices (e.g., gadget to put on socks)
I've simplified the task (sit to put on socks, wear shoes w/o laces)
I need the help of another person to dress
OTHER (specify)
.if (E12d = 0) E12dwarn
.if (E12d @ 7) E12dx
.next=E12e
.qu=E12dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E12d
.qu=E12dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E12e,type=number
For how long have you (changed or had difficulty
with or been unable to) dress yourself?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E13a,type=select
Do you have any difficulty
with the way you prepare you own meals?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E13a = 1) E13c
.if (E13a = 2) E13b
.if (E13a = 3) E13e
.if (E13a = 4) E14a
.if (E13a = 5) E14a
.if (E13a = 6) E13c
.next
.qu=E13b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty",
how much difficulty do you have
with the way you prepare you own meals?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E13c,type=select
Have you modified or changed the way you
prepare you own meals?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E13c = 2) E13d
.if ((E13a = 1 or E13a = 6) and (E13c = 1 or E13c = 3 or E13c = 4)) E14a
.lo=1
.hi=4
.next=E13e
.qu=E13d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
prepare you own meals?
(CHECK ALL THAT APPLY)
.an
I am slower when preparing meals
I am more careful or cautious when preparing meals
I prepare meals less often
I use assistive devices (e.g., microwave, cane)
I've simplified the task (use microwave, eat simple or frozen dinners)
I need the help of another person to prepare meals
OTHER (specify)
.if (E13d = 0) E13dwarn
.if (E13d @ 7) E13dx
.next=E13e
.qu=E13dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E13d
.qu=E13dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E13e,type=number
For how long have you (changed or had difficulty
with or been unable to) prepare you own meals?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E14a,type=select
Do you have any difficulty with the way you use the toilet
(including getting to and from the toilet)?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E14a = 1) E14c
.if (E14a = 2) E14b
.if (E14a = 3) E14e
.if (E14a = 4) E15a
.if (E14a = 5) E15a
.if (E14a = 6) E14c
.next
.qu=E14b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty",
how much difficulty do you have
with the way you use the toilet
including getting to and from the toilet?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E14c,type=select
Have you modified or changed the way you
use the toilet (including getting to and from the toilet)?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E14c = 2) E14d
.if ((E14a = 1 or E14a = 6) and (E14c = 1 or E14c = 3 or E14c = 4)) E15a
.lo=1
.hi=4
.next=E14e
.qu=E14d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
use the toilet (including getting to and from the toilet)?
(CHECK ALL THAT APPLY)
.an
I am slower in getting to or using the toilet
I am more careful or cautious when getting to or using the toilet
I use the toilet less often
I use assistive devices (raised toilet seat, grab bars, cane, walker)
I've simplified the task
I need the help of another person to get to or to use the toilet
OTHER (specify)
.if (E14d = 0) E14dwarn
.if (E14d @ 7) E14dx
.next=E14e
.qu=E14dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E14d
.qu=E14dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E14e,type=number
For how long have you (changed or had difficulty with or been unable to)
use the toilet (including getting to and from the toilet)?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E15a,type=select
Do you have any difficulty using the telephone?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E15a = 1) E15c
.if (E15a = 2) E15b
.if (E15a = 3) E15e
.if (E15a = 4) E16a
.if (E15a = 5) E16a
.if (E15a = 6) E15c
.next
.qu=E15b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have using the telephone?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E15c,type=select
Have you modified or changed the way you use the telephone?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E15c = 2) E15d
.if ((E15a = 1 or E15a = 6) and (E15c = 1 or E15c = 3 or E15c = 4)) E16a
.lo=1
.hi=4
.next=E15e
.qu=E15d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
use the telephone?
(CHECK ALL THAT APPLY)
.an
I am slower when I use the telephone
I am more careful or cautious when using the telephone
I use the telephone less often
I use assistive devices (volume button, hearing aide, auto dialing)
I've simplified the task (preprogram numbers, phone has large numbers)
I need the help of another person to use the telephone
OTHER (specify)
.if (E15d = 0) E15dwarn
.if (E15d @ 7) E15dx
.next=E15e
.qu=E15dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E15d
.qu=E15dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E15e,type=number
For how long have you (changed or had difficulty
with or been unable to) use the telephone?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E16a,type=select
Do you have any difficulty with the way you shop for personal items?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E16a = 1) E16c
.if (E16a = 2) E16b
.if (E16a = 3) E16e
.if (E16a = 4) E17a
.if (E16a = 5) E17a
.if (E16a = 6) E16c
.next
.qu=E16b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have with the way you shop for personal items?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E16c,type=select
Have you modified or changed the way you shop for personal items?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E16c = 2) E16d
.if ((E16a = 1 or E16a = 6) and (E16c = 1 or E16c = 3 or E16c = 4)) E17a
.lo=1
.hi=4
.next=E16e
.qu=E16d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you shop for personal items?
(CHECK ALL THAT APPLY)
.an
I am slower when I shop for personal items
I am more careful or cautious when shopping for personal items
I shop for personal items less often
I use assistive devices (e.g., electric cart, cane, walker, wheelchair)
I've simplified the task (shorter trips, get everything in one store)
I need the help of another person to shop for personal items
OTHER (specify)
.if (E16d = 0) E16dwarn
.if (E16d @ 7) E16dx
.next=E16e
.qu=E16dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E16d
.qu=E16dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E16e,type=number
For how long have you (changed or had difficulty with
or been unable to) shop for personal items?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E17a,type=select
Do you have any difficulty with the way you give yourself medications?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E17a = 1) E17c
.if (E17a = 2) E17b
.if (E17a = 3) E17e
.if (E17a = 4) E18a
.if (E17a = 5) E18a
.if (E17a = 6) E17c
.next
.qu=E17b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have with the way you give yourself medications?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E17c,type=select
Have you modified or changed the way you give yourself medications?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E17c = 2) E17d
.if ((E17a = 1 or E17a = 6) and (E17c = 1 or E17c = 3 or E17c = 4)) E18a
.lo=1
.hi=4
.next=E17e
.qu=E17d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
give yourself medications?
(CHECK ALL THAT APPLY)
.an
I am slower when I take my medications
I am more careful or cautious when taking medications
I give myself medications less often
I use assistive devices (e.g., pill box)
I've simplified the task (organize medicines, use reminders)
I need the help of another person to take my medications
OTHER (specify)
.if (E17d = 0) E17dwarn
.if (E17d @ 7) E17dx
.next=E17e
.qu=E17dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E17d
.qu=E17dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E17e,type=number
For how long have you (changed or had difficulty with
or been unable to) give yourself medications?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E18a,type=select
Do you have any difficulty with the way you
manage your own money such as paying bills?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E18a = 1) E18c
.if (E18a = 2) E18b
.if (E18a = 3) E18e
.if (E18a = 4) E19a
.if (E18a = 5) E19a
.if (E18a = 6) E18c
.next
.qu=E18b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have with the way you manage your own money such as paying bills?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E18c,type=select
Have you modified or changed the way you
manage your own money such as paying bills?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E18c = 2) E18d
.if ((E18a = 1 or E18a = 6) and (E18c = 1 or E18c = 3 or E18c = 4)) E19a
.lo=1
.hi=4
.next=E18e
.qu=E18d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
manage your own money such as paying bills?
(CHECK ALL THAT APPLY)
.an
I am slower at managing my money
I am more careful or cautious when managing my money
I manage my money less often
I use assistive devices (large print checks, magnifying glass)
I've simplified the task (rely on bank statements, use credit card)
I need the help of another person to manage my money
OTHER (specify)
.if (E18d = 0) E18dwarn
.if (E18d @ 7) E18dx
.next=E18e
.qu=E18dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E18d
.qu=E18dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E18e,type=number
For how long have you (changed or had difficulty with or been unable to)
manage your own money such as paying bills?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E19a,type=select
Do you have any difficulty with the way you do strenuous activities
(comparable to activities such as racquetball, jogging,
heavy construction work, swimming, or aerobic exercise)?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E19a = 1) E19c
.if (E19a = 2) E19b
.if (E19a = 3) E19e
.if (E19a = 4) E20a
.if (E19a = 5) E20a
.if (E19a = 6) E19c
.next
.qu=E19b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have do strenuous activities (comparable to activities
such as racquetball, jogging, heavy construction work, swimming,
or aerobic exercise)?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E19c,type=select
Have you modified or changed the way you do strenuous activities
(comparable to activities such as racquetball, jogging,
heavy construction work, swimming, or aerobic exercise)?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E19c = 2) E19d
.if ((E19a = 1 or E19a = 6) and (E19c = 1 or E19c = 3 or E19c = 4)) E20a
.lo=1
.hi=4
.next=E19e
.qu=E19d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you do strenuous activities
(comparable to activities such as racquetball, jogging,
heavy construction work, swimming, or aerobic exercise)?
(CHECK ALL THAT APPLY)
.an
I go slower when doing strenuous activities
I am more careful or cautious when doing strenuous activities
I do strenuous activities less often
I use assistive devices (i.e., knee brace)
I've simplified the task (do lower impact activities)
I need the help of another person to do strenuous activities
OTHER (specify)
.if (E19d = 0) E19dwarn
.if (E19d @ 7) E19dx
.next=E19e
.qu=E19dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E19d
.qu=E19dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E19e,type=number
For how long have you (changed or had difficulty with or been unable to)
do strenuous activities (comparable to activities such as racquetball,
jogging, heavy construction work, swimming, or aerobic exercise)?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E20a,type=select
Do you have any difficulty with the way you
do moderate activities such as playing golf,
bowling, vacuuming, or gardening?
.an=1
1 = No
2 = Yes
3 = No longer do this due to the difficulty of doing it
4 = No longer do this, but reasons are not related to my health
5 = Never did it
6 = Don't know / refused
.lo=1
.hi=6
.if (E20a = 1) E20c
.if (E20a = 2) E20b
.if (E20a = 3) E20e
.if (E20a = 4) E21a
.if (E20a = 5) E21a
.if (E20a = 6) E20c
.next
.qu=E20b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have doing moderate activities such as playing golf,
bowling, vacuuming, or gardening?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E20c,type=select
Have you modified or changed the way you
do moderate activities such as playing golf,
bowling, vacuuming, or gardening?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E20c = 2) E20d
.if ((E20a = 1 or E20a = 6) and (E20c = 1 or E20c = 3 or E20c = 4)) E21ax
.lo=1
.hi=4
.next=E20e
.qu=E20d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you
do moderate activities such as playing golf,
bowling, vacuuming, or gardening?
(CHECK ALL THAT APPLY)
.an
I am slower when doing moderate activities
I am more careful or cautious when doing moderate activities
I do moderate activities less often
I use assistive devices (i.e., knee brace)
I've simplified the task (do lower impact activities)
I need the help of another person to do moderate activities
OTHER (specify)
.if (E20d = 0) E20dwarn
.if (E20d @ 7) E20dx
.next=E20e
.qu=E20dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E20d
.qu=E20dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E20e,type=number
For how long have you (changed or had difficulty
with or been unable to) do moderate activities
such as playing golf, bowling, vacuuming, or gardening?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
************************************************************
.qu=E21ax,type=string
What is the most strenuous activity that you do?
TYPE IN YOUR ANSWER, THEN HIT THE "NEXT" BUTTON
.an=70
.next
.qu=E21a,type=number
Do you have any difficulty doing this activity?
1 = No
2 = Yes
.an=1
.lo=1
.hi=2
.if (E21a = 1) E21c
.if (E21a = 2) E21b
.next
.qu=E21b,type=number
On a scale of 1 to 10, where 1 means "a little difficulty"
and 10 means "a great deal of difficulty", how much difficulty
do you have doing this activity?
Some Difficulty Moderate Difficulty A Great Deal of Difficulty
1 2 3 4 5 6 7 8 9 10
<------------------------------------------------------------------>
.an=2
.lo=1
.hi=10
.next
.qu=E21c,type=select
Have you modified or changed the way you
do this activity?
.an=1
1 = No
2 = Yes, changed the way I do it FOR HEALTH REASONS
3 = Yes, but the change is NOT due to my health
4 = Don't know
.if (E21c = 2) E21d
.if ((E21a = 1 or E21a = 6) and (E21c = 1 or E21c = 3 or E21c = 4)) finish1
.lo=1
.hi=4
.next=E21e
.qu=E21d,type=check
.FOREGROUND=BLUE
.BACKGROUND=WHITE
.BORDER=YELLOW
How have you modified or changed the way you do this activity?
(CHECK ALL THAT APPLY)
.an
I am slower when doing this activity
I am more careful or cautious when doing this activity
I do this activity less often
I use assistive devices when doing this activity
I've simplified the task
I need the help of another person to do this activity
OTHER (specify)
.if (E21d = 0) E21dwarn
.if (E21d @ 7) E21dx
.next=E21e
.qu=E21dwarn,type=void
You did not select any responses.
Press the "back" key to return
to the previous question.
.an=1
PRESS "BACK"
.next=E21d
.qu=E21dx,type=string
SPECIFY OTHER CHANGES YOU MADE
.an=60
.next
.qu=E21e,type=number
For how long have you (changed or had difficulty with
or been unable to) do this activity?
(ROUND TO NEAREST YEAR)
- Enter '0' if less than 6 months
- Enter '1' if 6 months to 1 year
- If more than a year, type the number of years.
- Enter '88' if you don't know
.an=2
.lo=0
.hi=88
.next
*********************************************************************
.qu=finish1,type=void
Thank you for completing this questionnaire.
In order to exit the program, please click on "next".
This will close the program. Thank you.
.an=1
PLEASE PRESS NEXT
.next
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