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 Male   Female 
 Younger than 65 years    66-75 years    Over 75 years 

Patient Instructions: Please select the answer that best matches you.

 None 
 Cane
 Walker or crutches 
 Yes 
 No 
 None or 1 per week 
 2 or more times per week 
 2 blocks or more 
 1-2 blocks 
 Housebound