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  • By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does Sample Person (SP)} have . Dressing {yourself/himself/herself}, including tying shoes, working zippers, and doing buttons?
  • How much difficulty do you have standing or being on your feet for about 2 hourss [PhenX]
  • By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does Sample Person (SP)} have . . Sitting for about 2 hours?
  • By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does Sample Person (SP)} have . . Reaching up over {your/his/her} head?
  • By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does Sample Person (SP)} have . . Using {your/his/her} fingers to grasp or handle small objects?
  • By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does Sample Person (SP)} have . . . Going out to things like shopping, movies, or sporting events?
  • By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does Sample Person (SP)} have . . Participating in social activities [visiting friends, attending clubs or meetings or going to parties]?
  • By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does Sample Person (SP)} have . . Doing things to relax at home or for leisure [reading, watching TV, sewing, listening to music]?
  • By {yourself/himself/herself} and without using any special equipment, how much difficulty {do you/does Sample Person (SP)} have . . Pushing or pulling large objects like a living room chair?
  • Drinking water source Next-of-kin
  • Drinking water source other Next-of-kin
  • Well depth Next-of-kin
  • Was the private well cased [Next-of-kin]
  • Are any of the water treatment devices listed on this card used in your home [PhenX]
  • Water treatment current PhenX
  • Day sequence PhenX
  • Steps taken PhenX
  • Kinds of physical activity you usually performed while on the job this last year [PhenX]
  • Kinds of physical activity you usually performed during leisure time this last year [PhenX]
  • End time - right before going to sleep [PhenX]
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