Human Activity

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David M, Daughton,M.S. and A. ]ames Fix, ph.D. Narne

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Age-

Sex-

Date-

EducationList any medical problems or injuries which currently limit your activities:

Primary Score .

Score

Percentile

MASI AAS Activity Age

Fihress CIassification Low_

Activi ty Classification Impaired. Energy Anatysis EEP LEC Dyspnea Scale

FT

-'R

Y/'|!<

Fair

Average and above

Moderately active_

Score

Active

Percentile

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Qeorder 11457-Ig

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Instructions This booklet contains items which describe common activities that pee. ple do in their daity lives, Read each item carefully and place an "X" in the column which irrrCicateswhether you are still doing the activity, have stopped doing thb activity, or never did the activity. Use the followin$ inshuctions in making your responses:

Placean 'X' in the column marked StilI DoingThis Actioityif: you completed the activity unassisted thelast time you had the need or opportunity to do so. Placean 'X' in the column marked EIaoeStoppedDoingfhis Actioitylf: ),ou have engaged in the activity in the past, but you prob. ably would not perform the activity today even if you had the op.portunity.

Placean 'X'

irrthe cdumn marked I'lffirDiilThis

you.have

Actioityif:.

engagedin the specific activity. :**

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Activity

Gettingin andout of chairsor bed (withoutassistance) to the radio 2 . Listeninq 3. Readingbooks,magazinesor newsDaoers 4. Writinq(letters,notes) 5. Workinqat a deskor table 6. Standinq(formorethan 1 minute) 7 . Standinq(morethan5 minutes) (without 8. Dressingor undressing assistance) 9 . Geftingclothesfrom drawersor closets 1 0 . Gettingin or out of a car (without assistance) 11 . Dininqat a restaurant 12. Plavinqcards/tableqames 1 3 . Takinqa bath(no assistanceneeded) 1 4 . Puftingon shoes,stockingsor socks (no restor breakneeded) 1 5 . Attendinga movie,play,churchevent or sportsactivity 1 6 . Walkinq30 vards(27 metres) 1 7 . Walkinq30 vards(non-stop) (no restor break 1 8 . Dressing/undressing needed) or driving 1 9 . Usingpublictransportation a car (160kmor Iess) or driving 20. Usingpublictransportation (160km more) or a car 2 1 . Cookinqyour own meal 22. Washinqor drvinq clothes 23. Puttinqqrocerieson shelves 24. lroninqor foldinq clothes furnitureor car 25. Dustinq/polishinq 26. Showerinq 27. Climbins 28. Climbinq6 steps 29. Climbinq6 steps(nonstop) 30. Climbinq12 steps 3 1 . Wafkinqlzblock on qround level 32. Walking lzblock on levelground 1.

(non-stop) 33. Makinoa bed (not chanqinqsheets)

Still doing Have stopped this activity doing this activity

Neverdid this activity

-

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Activity

Stilldoing Have this sfopped activity doing this activity

34. 35. 36. 37. 38. 39. 40. 41 .

42. 43. 44.

45. 46.

47. 48. 49.

Cleaning windows Kneeling / squattinqto do lightwork Carryinqa liqhtloadof oroceries g steps(non-stoo) Climbinq Climbinq 12steps(non-stop) Walkinq% blockuphill Walking/,block uphill(non-stop) Shoppinq(by yourselfl Washingclothes(by yourself) Walking1 blockon level qround Walkinq2 blockson level qround Walking1 block on level ground (nonstop) Walking2 blockson levelground (non-stop) Scrubbinq(floors.walls or cars) Makinga bed (chanqinqsheets) Sweeping

50. Sweepinq(5 minutesnon-stoo) 5 1 . Carryinga largesuitcaseor bowling (onegame) 52. Vacuuminqcarpet 53. Vacuuming carpet(5 minutesnonstop) 54. Painti ng (interior/exterior) 55. Walking6 blockson level qround

56. Walking6 blockson level ground 57 . 58. 59.

(non-stop) Carryingout the qarbaqe Carryingheaw load of qroceries Climbing24 steps Climbing36 steps Climbing24 steps (non-stop)

60. 61. 62. Climbing 36 steps(non-stoo) 6 3 . Walkinq1 mile(1.6km)

64. Walking1 mile (1.6 km) (non-stop) 65. Running100metres,playing

softball/baseball 66. Dqncing(social) 67 . Doingcalisthenics or aerobicdancing

(5 nlinutesnon-stop)

68. Mowingthe lawn(powermowernot a

ride-onmower)

Neverdid fhis activity

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Activity

69. 70. 71. 72. 73. 74.

75. 76. 77. 78.

Walkinq2 miles(3.2km) Walkinq2 miles(3.2km)(non-stop) Climbinq50 stepsQl"floorsl Shovelinq,diqqinqor usinq a spade

Shoveling, diggingor usinga spade (5 minutesnon-stop) Climbinq50 steps(non-stop) Walking3 miles(a.8km)or golfing18 holeswithouta ridinqcart Walkinq3 miles(4.8km) (non-stop) 25 yards(22.5m) Swimming (aporoxlzlaa Olvmpicsize pool) Swimming 25 yards(22.5m)(nonstop) (aoproxYzlaoOlympicsize pool)

79 . Bicyclinq1 mile (1.6km) 80. Bicvclinq1 mile (1.6km)(non-stop)

81. 82. 83. 84.

Bicvclinq2 miles(3.2km) Bicyclinq2 miles(3.2km)(non-stop) Runninqor ioqqinqlamile (400m)

Runninqor ioqqinqlzmile (800m)

85. Plavinqtennisor racquetball (playgame 86. PlayingbasketbalUsoccer

soort) 8 7 . Runningor joggingT.mile(a00m) (non-stop) 88. Runningorjogging lzmile (800m) {non-stoo) 89. Runninqor ioqqinq1 mile (1.6km) 90. Runninqor ioqqinq2 miles (3.2km) 9 1 . Runninqor ioqoinq3 miles (4.8km)

92. Runningorjogging1 mile(1.6km)in 12 minutesor less 93. Runningor jogging2 miles(3.2km) in 20 minutesor less 94. Running or jogging3 miles(4.8km)in 30 minutesor less

Still doing Have sfopped this doing this activity activity

Never did fhis activity