Physical Function Questionnaire

The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Please mark one box on each line.

Your age:
Your sex: Male Female

	Yes - Limited a lot	Yes - Limited a little	No - Not limited at all
1. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
2. Moderate activities, such as moving a table, pushing a vacumn cleaner, bowling or playing golf
3. Lifting or carrying groceries
4. Climbing several flights of stairs
5. Climbing one flight of stairs
6. Bending, kneeling or stooping
7. Walking more than a mile
8. Walking several blocks
9. Walking one block
10. Bathing or dressing yourself

Now you will be asked 5 questions about how much your symptoms bothered you over the last week. Were they not bothersome at all, extremely bothersome or something in between? Please mark one box for each question.

Symptoms

On a 0 to 6 point scale, please rate the following symptoms according to how bothersome they were in the PAST WEEK.	Not bothersome		Somewhat bothersome			Extremely bothersome
	0	1	2	3	4	5	6
1. Leg pain?
2. Numbness or tingling in leg, foot or groin?
3. Weakness in leg or foot?
4. Leg pain after walking?