Below each question, select the answer that best describes how you feel. The questions are broken up into three aspects: Physical, Emotional, and Functional Questions Does looking upward worsen your problem? (Aspect: Physical) No (0) Sometimes (2) Yes (4) Do you feel frustrated because of your problem? (Aspect: Emotional) No (0) Sometimes (2) Yes (4) Do you limit your business or leisure travels because of your problem? (Aspect: Functional) No (0) Sometimes (2) Yes (4) Does walking through the corridor of a supermarket worsen your problem? (Aspect: Physical) No (0) Sometimes (2) Yes (4) Do you find it difficult to lay down or get up from bed because of your problem? (Aspect: Functional) No (0) Sometimes (2) Yes (4) Does your problem significantly restrict your participation in social activities? (Aspect: Functional) No (0) Sometimes (2) Yes (4) Do you find it hard to read because of your problem? (Aspect: Functional) No (0) Sometimes (2) Yes (4) Does your problem get worse when you perform more difficult activities such as, sports, dancing, indoor chores such as, sweeping and cleaning dishes? (Aspect: Physical) No (0) Sometimes (2) Yes (4) Because of your problem, do you feel afraid of going out without someone who accompanies you? (Aspect: Emotional) No (0) Sometimes (2) Yes (4) Because of your problem, do you feel ashamed about the presence of other people? (Aspect: Emotional) No (0) Sometimes (2) Yes (4) Do quick movements of your head worsen your problems? (Aspect: Physical) No (0) Sometimes (2) Yes (4) Due to your problem, do you avoid high places? (Aspect: Functional) No (0) Sometimes (2) Yes (4) Does turning in bed worsen your problem? (Aspect: Physical) No (0) Sometimes (2) Yes (4) Because of your problem, is it difficult for you to do indoor or outdoor chores? (Aspect: Functional) No (0) Sometimes (2) Yes (4) Because of your problem, do you fear that people think you are drugged or drunk? (Aspect: Emotional) No (0) Sometimes (2) Yes (4) Because of your problem, is it difficult for you to get out for a walk without help? (Aspect: Functional) No (0) Sometimes (2) Yes (4) Does walking on the sidewalk worsen your problem? (Aspect: Physical) No (0) Sometimes (2) Yes (4) Because of your problem, is it difficult for you to concentrate? (Aspect: Emotional) No (0) Sometimes (2) Yes (4) Because of your problem, is it difficult for you to walk into your house in the dark? (Aspect: Functional) No (0) Sometimes (2) Yes (4) Due to your problem, do you fear staying home alone? (Aspect: Emotional) No (0) Sometimes (2) Yes (4) Due to your problem, do you feel disabled? (Aspect: Emotional) No (0) Sometimes (2) Yes (4) Does your problem damage your relationship with your relatives or friends? (Aspect: Emotional) No (0) Sometimes (2) Yes (4) Due to your problem, are you depressed? (Aspect: Emotional) No (0) Sometimes (2) Yes (4) Does your problem interfere with your work or duties at home? (Aspect: Functional) No (0) Sometimes (2) Yes (4) Does becoming inclined worsen our problem? (Aspect: Physical) No (0) Sometimes (2) Yes (4) First Name Last Name Email Phone Time's up