| 1. Any of your usual work, housework, or school activities | | | | | |
| 2. Your usual hobbies, recreational or sporting activities | | | | | |
| 3. Lifting a bag of groceries to waist level | | | | | |
| 4. Lifting a bag of groceries above your head | | | | | |
| 5. Grooming your hair | | | | | |
| 6.Pushing up on your hands (eg from bathtub or chair) | | | | | |
| 7. Preparing food (eg. peeling, cutting) | | | | | |
| 8. Driving | | | | | |
| 9. Vacuuming, sweeping or raking | | | | | |
| 10.Dressing | | | | | |
| 11. Doing up buttons | | | | | |
| 12.Using tools or appliances | | | | | |
| 13. Opening doors | | | | | |
| 14. Cleaning | | | | | |
| 15. Tying or lacing shoes | | | | | |
| 16. Sleeping | | | | | |
| 17. Laundering clothes (eg. washing, ironing, folding) | | | | | |
| 18. Opening a jar | | | | | |
| 19. Throwing a ball | | | | | |
| 20.Carrying a small suitcase with your affected limb | | | | | |