Member Wellness Assessment

Name*

First NameLast Name
Email*
example@example.com
Are you able to do chores such as vacuuming or yard work?*

Without Any DifficultyWith A Little DifficultyWith Some DifficultyWith Much DifficultyUnable To Do
Are you able to go up and down stairs at a normal pace?*

Without Any DifficultyWith A Little DifficultyWith Some DifficultyWith Much DifficultyUnable To Do
Are you able to go for a walk of at least 15 minutes?*

Without Any DifficultyWith A Little DifficultyWith Some DifficultyWith Much DifficultyUnable To Do
Are you able to run errands and shop?*

Without Any DifficultyWith A Little DifficultyWith Some DifficultyWith Much DifficultyUnable To Do
Are you able to carry a shopping bag or briefcase?*

Without Any DifficultyWith A Little DifficultyWith Some DifficultyWith Much DifficultyUnable To Do
Are you able to wash your back?*

Without Any DifficultyWith A Little DifficultyWith Some DifficultyWith Much DifficultyUnable To Do
Are you able to get in and out of bed?*

Without Any DifficultyWith A Little DifficultyWith Some DifficultyWith Much DifficultyUnable To Do
Are you able to stand for one hour?*

Without Any DifficultyWith A Little DifficultyWith Some DifficultyWith Much DifficultyUnable To Do
Are you able to bend down to pick something up from floor?*

Without Any DifficultyWith A Little DifficultyWith Some DifficultyWith Much DifficultyUnable To Do
Are you able to ooen a new milk container?*

Without Any DifficultyWith A Little DifficultyWith Some DifficultyWith Much DifficultyUnable To Do
Total Score
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