151 Activities of Daily Life

Ver. 9
OMB #0925-0414 Exp: 7/13

Form 151– Activities of Daily Life

*151-9*
This form has questions about your current experiences. Please answer the questions as
honestly as you can, using your first thoughts about each question. You should not go back
later to “figure out” answers. Please answer the questions on both sides. Your answers will
be kept confidential and will never be put with your name in a published report, but they
will help us to understand the health of women like you. Thank you for your help.
1.

In general, would you say your
health is: (Mark one circle only.)

Very
good

Excellent
1

2.

3

Fair

Poor

4

5

Overall, how would you rate your quality of life? (Mark one circle below.)
0

1

2

3

4

5

Worst
As bad or worse
than being dead
3.

Good

2

6

7

8

9

Halfway

10
Best
Best quality
of life

Does the place (home, apartment, assisted living facility) where you live have special services for
older people (such as help with transportation, meals, medicines, or bathing)?
0

No

1

3.1. Are you currently receiving any of these services?
0 No
1 Yes

Yes

4.

In the past year, have you stayed in a nursing home?
0 No
1 Yes

5.

What aid, if any, do you
usually use to walk on a level
surface? (Mark one.)

I do not
use any aid

I use a
cane

1

I use
crutches

2

I use a
walker

3

I use a
wheelchair

4

5

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collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0414). Do not return the completed form to this address.

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Month

Day

3. Contact Type:
1 Phone
2 Mail
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Year

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1

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U.S. GOVERNMENT PRINTING OFFICE:2010–776-300/40061

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Ver. 9

Form 151– Activities of Daily Life

OMB #0925-0414 Exp: 7/13

6. Are you taking a calcium supplement such as Oscal, Viactiv, or Tums?
0

No

1

Yes

The following are questions about a typical (or usual) day’s activities. Does your health now limit
you in these activities and, if so, how much? (Mark one circle for each question.)
No,
not limited
at all

Yes,
limited
a little

Yes,
limited
a lot

7.

Vigorous activities, such as running, lifting
heavy objects, or strenuous sports

3

2

1

8.

Moderate activities, such as moving a table,
vacuuming, bowling, or golfing

3

2

1

9.

Lifting or carrying groceries

3

2

1

10.

Climbing several flights of stairs

3

2

1

11.

Climbing one flight of stairs

3

2

1

12.

Bending, kneeling, stooping

3

2

1

13.

Walking more than a mile

3

2

1

14.

Walking several blocks

3

2

1

15.

Walking one block

3

2

1

3

2

1

16. Bathing or dressing yourself

These next questions ask about how much help (if any) you need to do routine activities for yourself.
Help can be defined as getting assistance from another person or using a device. (Mark one circle for
each question.)
I can do this activity:

By myself
without
help

With some
help

Completely
unable to do
this by myself

17. Can you feed yourself?

1

2

3

18. Can you dress and undress yourself?

1

2

3

19. Can you get in and out of bed yourself?

1

2

3

20. Can you take a bath or shower?

1

2

3

1

2

3

1

2

3

21.

Can you do your own grocery shopping?

22. Can you keep track of and take your medicines?
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