• These questions ask about limitations to your walking due to MS during the past 2 weeks.
• For each statement, please circle the one number that best describes your degree of limitation.
• Please answer all questions even if some seem rather similar to others, or seem irrelevant to you.
• If you cannot walk at all, please tick this box.
In the past two weeks, how much has your MS ... Not at all
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A little
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Moderately
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Quite a bit
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Extremely
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1. Limited your ability to walk? 1 2 3 4 5
2. Limited your ability to run? 1 2 3 4 5
3. Limited your ability to climb up and down stairs? 1 2 3 4 5
4. Made standing when doing things more difficult? 1 2 3 4 5
5. Limited your balance when standing or walking? 1 2 3 4 5
6. Limited how far you are able to walk? 1 2 3 4 5
7. Increased the effort needed for you to walk? 1 2 3 4 5
8. Made it necessary for you to use support when walking indoors (e.g., holding on to furniture, using a stick, etc.)? 1 2 3 4 5
9. Made it necessary for you to use support when walking outdoors (e.g., using a stick, a frame, etc.)? 1
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2 3 4 5
10. Slowed down your walking? 1 2 3 4 5
11. Affected how smoothly you walk? 1 2 3 4 5
12. Made you concentrate on your walking? 1 2 3 4 5
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Please check that you have circled ONE number for EACH question
© 2000 Neurological Outcome Measures Unit.
Monday, April 26, 2010
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