What's your physical function level?

Do you physically exercise/train regularly?
Yes
No
How would you rate your function fitness?
High Functioning
Medium Functioning
Low Functioning
Rate your functional fitness level:
You've achieved your highest level of fitness
You exercise for health & well-being
You perform one or two types of exercises really well
You exercise occasionally
You do not exercise and are mostly sedentary
You still grocery shop, cook, and bath on your own, but need intervention soon to keep from declining
You can bath and feed yourself, but can no longer do the shopping and cooking
You depend on others and physical aids to help you complete basic necessities
Do you have trouble getting up?
Just like me
Somewhat like me
A little like me
Nothing like me
Do you shuffle your feet? / Does the sole of your shoe wear out in certain places quicker than others?
Just like me
Somewhat like me
A little like me
Nothing like me
Do you feel unsteady when you walk?
Just like me
Somewhat like me
A little like me
Nothing like me
Do you prefer to walk with support?
Yes
No
How many times a week do you exercise?
0-1
2-3
4-5
5-6
6+
You spend most of your time sitting?
Just like me
Somewhat like me
A little like me
Nothing like me
You find joy in your fitness level and content with your efforts to maintain it.
Just like me
Somewhat like me
A little like me
Nothing like me
You are dependent on others to help you.
Just like me
Somewhat like me
A little like me
Nothing like me
I want to improve my current functional level.
Yes
No
You are at your highest level of physical function.
Yes
No
You exercise primarily for your health and well-being on a regular basis.
Yes
No
You excel at one or two areas of fitness rather than excelling at most or all areas.
Yes
No
You are physically active but do not exercise on a regular basis.
Yes
No
You are minimally active or completely sedentary.
Yes
No
You are on a steep downward functional trajectory towards frailty and dependence.
Yes
No
You are at increased risk of disability and death from minor stresses.
Yes
No
You can perform most or all basic activities of daily living, like bathing, dressing, and feeding, but are not able to perform instrumental activities of daily living, like shopping, doing laundry, cooking, or cleaning.
Yes
No
You are unable to perform all the basic activities of daily living, like bathing, dressing, or feeding, and are dependent on others or physical aids to complete daily tasks.
Yes
No
Email:
Name:
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