Question 1: Can you balance on your left foot for 10 seconds?

Yes

No

Question 2: Can you balance on your right foot for 10 seconds?

Yes

No

Question 3: Can you stand with your back to the wall and touch the wall with your head, elbows, and knuckles all at the same time?

Yes

No

Question 4: Can you reach your toes?

Yes

No

Question 5, part 1: Can you get up from the floor without using a chair or getting assistance from another person?

Yes

No

Question 6: Rate Yourself on Your Ability to Get Out of Bed

Without Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do This

Question 7: Rate Yourself on Your Ability to Run Errands and Shop

Without Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do This

Question 8: Rate Yourself on Your Ability to Walk Outdoors on Flat Ground

Without Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do This

Question 9: Rate Yourself on Your Ability to Climb Up a Flight of Stairs

Without Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do This

Question 10: Rate Yourself on Your Ability to Get In/Out of a Car

Without Difficulty

With Some Difficulty

With Much Difficulty

Unable To Do This

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