Basic Mobility Sample Items: total number of items in this domain = 101
How much DIFFICULTY do you (does the patient) currently have…?
• moving from lying on your back to sitting on side of the bed
• getting up from the floor
• reaching overhead while standing, as if to pull a light cord
• using an escalator?
• going up and down a flight of stairs inside, using a handrail
• walking around inside a building (50 ft, or 16 meters) on the same level
• going up and down three flights of stairs inside, using a handrail
• carrying something in both arms while climbing a flight of stairs (e.g., laundry basket
• climbing stairs step-over-step without a handrail? (alternating feet)
• walking quickly indoors to answer the telephone
• lifting 25 pounds (e.g., dog food or a large bag of fertilizer)
• carrying 2 plastic grocery bags with handles at your side for 50 feet
• making sharp turns when running fast
• climbing a step ladder (4-5 steps)
• doing moderately heavy house or yard work (e.g., changing a ceiling light bulb, hanging a picture on the wall, weeding a garden, or sweeping a walkway)
• taking part in strenuous activities (e.g., running 3 miles, swimming half mile, etc.)
Daily Activity sample items: total number of items in this domain = 70
How much DIFFICULTY do you (does the patient) currently have…?:
reaching behind your back to put a belt through the loop
• inserting a key in a lock and turning it to unlock the door
• unscrewing the lid off a previously unopened jar without using devices
• cutting with scissors (e.g., to open a package or cut out coupons)
• getting money in and out of your wallet
• operating an ATM to get cash or make deposits
• cutting your toenails
• tying shoes
• opening medication or vitamin containers (e.g., childproof containers, small bottles) and managing individual tablets
• managing toileting aftercare, including cleaning, managing undergarments, and arranging clothes
• using a stove or hot plate to cook a meal or prepare a hot drink, including turning on or off, adjusting heat, and moving hot items around
using washer and dryer, including loading and unloading clothes, and setting the dials
Applied Cognitive: total number of items in this domain = 69
How much DIFFICULTY do you (does the patient) currently have…?:
• explaining how to do something involving several steps to another person
• following/understanding a 10 to 15 minute speech or presentation (e.g. lesson at a place of worship, guest lecture at a senior center
) • describing something that has happened to you so that others can understand you
• carrying on a conversation with a small group (e.g., family or a few friends)
• telling someone that what they are doing is bothering you (e.g., interrupting or making noise that is distracting)
• getting to know new people
• reading a long book (over 100 pages) over a number of days
• reading and following complex instructions (e.g., directions to operate a new appliance or for a new medication)
• looking up a phone number or address in the phone book or in your own address book
• filling out a long form (e.g., insurance forms or an application for services)
• writing down a short message or note
• planning for and keeping appointments that are not part of your weekly routine, e.g., a therapy, doctor appointment, or a social gathering with friends and family
• remembering to take medications at the appropriate time
• using a calendar, or weekly activity planner to keep track of appointments and events
• putting together a shopping list of 10 to15 items