1

Causing swelling in your ankles or legs?

0

1

2

3

4

5

2

Making you sit or lie down to rest during the day?

0

1

2

3

4

5

3

Making your walking about or climbing stairs difficult?

0

1

2

3

4

5

4

Making your working around the house or yard difficult?

0

1

2

3

4

5

5

Making your going places away from home difficult?

0

1

2

3

4

5

6

Making your sleeping well at night difficult?

0

1

2

3

4

5

7

Making your relating to or doing things with your friends or family difficult?

0

1

2

3

4

5

8

Making your working to earn a living difficult?

0

1

2

3

4

5

9

Making your recreational past times, sports or hobbies difficult?

0

1

2

3

4

5

10

Making you eat less of the foods you like?

0

1

2

3

4

5

11

Making you short of breath?

0

1

2

3

4

5

12

Making you tired, fatigued, or low on energy?

0

1

2

3

4

5

13

Making you stay on a hospital?

0

1

2

3

4

5

14

Costing you money for medical care?

0

1

2

3

4

5

15

Giving you side effects from treatments?

0

1

2

3

4

5

16

Making your sexual activities difficult?

0

1

2

3

4

5

17

Making you feel you are a burden to your family?

0

1

2

3

4

5

18

Making you feel a loss of self-control in your life.

0

1

2

3

4

5

19

Making you worry

0

1

2

3

4

5

20

Making it difficult for you to concentrate or remember things?

0

1

2

3

4

5

21

Making you feel depressed?

0

1

2

3

4

5