Protocol - Physical Mobility - Adult

Without any difficulty

With a little difficulty

With some difficulty

With much difficulty

Unable to do

Are you able to stand for one hour?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to stand up from an armless straight chair?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to run or jog for two miles (3 km)?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to go up and down stairs at a normal pace?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to go for a walk of at least 15 minutes?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to step up and down curbs?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to stand with your knees straight?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to stand for short periods of time?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to run at a fast pace for two miles (3 km)?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to squat and get up?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to climb up five steps?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to run a short distance, such as to catch a bus?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to stand unsupported for 10 minutes?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to stand up on tiptoes?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to stand unsupported for 30 minutes?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to jump up and down?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to run 100 yards (100 m)?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to walk up and down two steps?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to climb up 5 flights of stairs?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to walk at a normal speed?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to stand without losing your balance for several minutes?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to kneel on the floor?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to walk a block (about 100 m) on flat ground?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to run five miles (8 km)?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to climb the stairs of a 10-story building without stopping?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to walk briskly for 20 minutes without stopping to rest?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to come to a complete stop while running?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to make sharp turns while running fast?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to jump over an object that is 1 foot (30 cm) tall?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to jump 2 feet (60 cm) high?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to walk across a balance beam?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to walk in a straight line putting one foot in front of the other (heel to toe) for 5 yards (5 m)?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to dance energetically for an hour?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to run on uneven ground?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to run on even ground?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to run ten miles (16 km)?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Are you able to stand on one foot with your eyes closed for 30 seconds?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Does your health now limit you in bending, kneeling, or stooping?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Does your health now limit you in going for a short walk (less than 15 minutes)?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Does your health now limit you in hiking a couple of miles (3 km) on uneven surfaces, including hills?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Does your health now limit you in climbing several flights of stairs?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Does your health now limit you in walking more than a mile (1.6 km)?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Does your health now limit you in climbing one flight of stairs?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1

Does your health now limit you in walking about the house?

[ ]
5

[ ]
4

[ ]
3

[ ]
2

[ ]
1