1.       FAMILY/HOME RESPONSIBILITIES

This refers to activities related to the home or family. It includes chores around the house (e.g. cleaning, gardening) and errands or favours for other family members (e.g. driving children to school etc.)

PLEASE RATE                                                                                                

0

1

2

3

4

5

6

7

8

9

not applicable

NO DISABILITY                                                                               TOTAL DISABILITY

2. RECREATION

This  refers to your hobbies, sports, and other similar leisure time activities.

PLEASE RATE                                                                                                

0

1

2

3

4

5

6

7

8

9

not applicable

NO DISABILITY                                                                               TOTAL DISABILITY

3.       SOCIAL ACTIVITY

This refers to activities which involve participation with friends and acquaintances or family members. It includes parties, theatre, concerts, dining out and other social functions.

PLEASE RATE                                                                                                

0

1

2

3

4

5

6

7

8

9

not applicable

NO DISABILITY                                                                               TOTAL DISABILITY

4.       OCCUPATION

This refers to activities which are part of your job, including unpaid work such as volunteer work and being a housewife.

PLEASE RATE                                                                                                 

0

1

2

3

4

5

6

7

8

9

not applicable

NO DISABILITY                                                                               TOTAL DISABILITY