Difficulties in carrying out everyday activities
For all members of the household, specify the degree of difficulty the person has in
[Questions 16 to 21 were asked of all household members]
16. Seeing
[] 0 Without difficulty (SD)
[] 1 Slight difficulty (DL)
[] 2 Considerable difficulty (GD)
[] 3 Unable to do so (IN)
17. Hearing
[] 0 Without difficulty (SD)
[] 1 Slight difficulty (DL)
[] 2 Considerable difficulty (GD)
[] 3 Unable to do so (IN)
18. Waling or climbing stairs
[] 0 Without difficulty (SD)
[] 1 Slight difficulty (DL)
[] 2 Considerable difficulty (GD)
[] 3 Unable to do so (IN)
19. Remembering or focusing
[] 0 Without difficulty (SD)
[] 1 Slight difficulty (DL)
[] 2 Considerable difficulty (GD)
[] 3 Unable to do so (IN)
20. Taking care of him/herself, such as bathing or dressing
[] 0 Without difficulty (SD)
[] 1 Slight difficulty (DL)
[] 2 Considerable difficulty (GD)
[] 3 Unable to do so (IN)
21. Communicating in his/her usual language
[] 0 Without difficulty (SD)
[] 1 Slight difficulty (DL)
[] 2 Considerable difficulty (GD)
[] 3 Unable to do so (IN)