Questions:

1. Overall, how much of a problem did [name] have with moving around?
2. How much difficulty did [name of person] have in vigorous activities, such as running 2 miles or cycling?

1. None
2. Mild
3. Moderate
4. Severe
5. Extreme

Vignettes:

1. [Name] is able to walk distances of up to 1/8 mile without any problems but feels tired after walking 1/2 mile or climbing up more than one flight of stairs. He [She] has no problems with day-to-day physical activities, such as carrying food from the market.

2. [Name] does not exercise. He [She] cannot climb stairs or do other physical activities because he [she] is obese. He [She] is able to carry the groceries and do some light household work.

3. [Name] has a lot of swelling in his [her] legs due to his health condition. He [She] has to make an effort to walk around his home as his [her] legs feel heavy.

4. [Name] is able to move his [her] arms and legs, but requires assistance in standing up from a chair or walking around the house. Any bending is painful and lifting is impossible.