Q1

Do you have any trouble doing strenuous activities like carrying a heavy shopping bag or suitcase?

Y

N

Q2

Do you have any trouble taking a long walk?

Y

N

For the following question please circle the number between 1 and 7 that best applies to you.

Q29

How would you rate your overall health during the past week?

1

2

3

4

5

6

7

Very poor

Excellent