Question 3 The followmg items are about activities you might do during a typical day- Does your heaibh now limit
you in these activities? If so, how much?


 Activities Yes, Yes, No, Not
 Limited A Lt Limited A Little Limited At All

 a. Vigorous activities, such as running, lifting heavy 1 2 3
 objects, iFtidcip;tirng in strenuous sports


 b. Moderate activities, such as moving a table, pushing a 1 2 3
 vacuum clear, bowling, or playing golf


 c. Lifting or carrying groceries 1 2 3

 d. Climbing several flights of stairs 1 2 3

 e. Climbing one flight of stairs 1 2 3

 f. Bending, kneeling, or stooping 1 2 3

 g. Walking more than a mile 1 2 3

 h. Walking several blocks 1 2 3

 i. Walking one block I 2 3

 j. Bathing or dressing yourself 1 2 3