ffiwffieru

ACTHWgT
PffiffiFHLffi {^ffiVH
David M, Daughton,M.S. and A.
]ames Fix, ph.D.

Narne
, Age- Sex- Date-
occuPatio
Education-
List any medical problems or injuries which
currently limit your activities:

Primary Score Score Percentile

. MASI
AAS
Activity Age
Fihress CIassification
Low_ Fair Average and above
Activi ty Classification
Impaired. Moderately active_ Active
Energy Anatysis Score Percentile
EEP
LEC
Dyspnea Scale

FT -'R
Y/'|!< PsychologicolAssessrnenlResources,lnc.
co. 8oxgga/odessq
Fbido33556/ Teteptrone
(&13)
96&3003
SUPy^9 1900'.1904.t90s byPs!'*torcdcol^rsesenent Re3orrcs, h|c Ar rtehh.eeryed.
oy ony p'ocets or by ooy rDeonswitt ora iinen perrnir:brr of pq6horog,lcot l.roilo be reprodrred -x.r
v/hote or in porl
AsteaJrnentResorrcer hc.
987654321
tuhfedin lheUS,{
Iha lorm is printed in r,orooo i* on tvory poper-
Arry olt€, version B unoothorted.
Qeorder 11457-Ig
 i
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 Actioityif:.

you.have engagedin the specific activity.

:**
f-iu;n*nA*iiiriiyfiafiie
itl.$. *n* h. Jamesfix. FhD
t]*vid tvl.li*i";g?":i*n,

Activity Still doing Have Neverdid

this stopped this
activity doing this activity
activity
1. Gettingin andout of chairsor bed
(withoutassistance)
2 . Listeninq to the radio
3. Readingbooks,magazinesor
newsDaoers
4. Writinq(letters,notes)
5. Workinqat a deskor table
6. Standinq(formorethan 1 minute)
7 . Standinq(morethan5 minutes)
8. Dressingor undressing (without
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)
1 8 . Dressing/undressing (no restor break
needed)
1 9 . Usingpublictransportation or driving
a car (160kmor Iess)
20. Usingpublictransportation or driving
a car (160km or more)
2 1 . Cookinqyour own meal
22. Washinqor drvinq clothes
23. Puttinqqrocerieson shelves
24. lroninqor foldinq clothes
25. Dustinq/polishinq furnitureor car
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
(non-stop)
33. Makinoa bed (not chanqinqsheets)
 -

ii r;;::a;ri&*!i ;1i-';? s*iiir:

**viij fi. **L;ghion, f,i'i.$.anr! A. ,"j*inesFix, phD

Activity Stilldoing Have Neverdid

this sfopped fhis
activity doing this activity
activity
34. Cleaningwindows
35. Kneeling/ squattinqto do lightwork
36. Carryinqa liqhtloadof oroceries
37. Climbinqg steps(non-stoo)
38. Climbinq12steps(non-stop)
39. Walkinq% blockuphill
40. Walking/,block uphill(non-stop)
41 . Shoppinq(by yourselfl
42. Washingclothes(by yourself)
43. Walking1 blockon level qround
44. Walkinq2 blockson level qround
45. Walking1 block on level ground (non-
stop)
46. Walking2 blockson levelground
(non-stop)
47. Scrubbinq(floors.walls or cars)
48. Makinga bed (chanqinqsheets)
49. Sweeping
50. Sweepinq(5 minutesnon-stoo)
5 1 . Carryinga largesuitcaseor bowling
(onegame)
52. Vacuuminqcarpet
53. Vacuuming carpet(5 minutesnon-
stop)
54. Painti ng (interior/exterior)
55. Walking6 blockson level qround
56. Walking6 blockson level ground
(non-stop)
57 . Carryingout the qarbaqe
58. Carryingheaw load of qroceries
59. Climbing24 steps
60. Climbing36 steps
61. Climbing24 steps (non-stop)
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)
i''ii;r"n;*': A*tivity ? r*itir:
*avi,: lvl.ila'r;cht*n,1,,4.3. *nri ,{. JarnesFix, Phil

Activity Still doing Have Never did

this sfopped fhis
activity doing this activity
activity
69. Walkinq2 miles(3.2km)
70. Walkinq2 miles(3.2km)(non-stop)
71. Climbinq50 stepsQl"floorsl
72. Shovelinq,diqqinqor usinq a spade
73. Shoveling,diggingor usinga spade
(5 minutesnon-stop)
74. Climbinq50 steps(non-stop)
75. Walking3 miles(a.8km)or golfing18
holeswithouta ridinqcart
76. Walkinq3 miles(4.8km) (non-stop)
77. Swimming 25 yards(22.5m)
(aporoxlzlaa Olvmpicsize pool)
78. Swimming 25 yards(22.5m)(non-
stop)
(aoproxYzlaoOlympicsize pool)
79 . Bicyclinq1 mile (1.6km)
80. Bicvclinq1 mile (1.6km)(non-stop)
81. Bicvclinq2 miles(3.2km)
82. Bicyclinq2 miles(3.2km)(non-stop)
83. Runninqor ioqqinqlamile (400m)
84. Runninqor ioqqinqlzmile (800m)
85. Plavinqtennisor racquetball
86. PlayingbasketbalUsoccer(playgame
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