| LP134219-7 | How much difficulty do you currently have walking on a slippery surface, outdoors | COMPONENT | 1 |
| LP134220-5 | How much difficulty do you currently have climbing stairs step over step without a handrail - alternating feet | COMPONENT | 1 |
| LP134221-3 | How much difficulty do you currently have walking in a dark room without falling | COMPONENT | 1 |
| LP134222-1 | How much difficulty do you currently have checking the accuracy of financial documents, like bills, checkbook, or bank statements | COMPONENT | 1 |
| LP134223-9 | How much difficulty do you currently have counting the correct amount of money when making purchases | COMPONENT | 1 |
| LP134224-7 | How much difficulty do you currently have reading and following complex instructions, like directions for a new medication | COMPONENT | 1 |
| LP134225-4 | How much difficulty do you currently have planning for and keeping appointments that are not part of your weekly routine, like a therapy or doctor appointment, or a social gathering with friends and family | COMPONENT | 1 |
| LP134226-2 | How much difficulty do you currently have managing your time to do most of your daily activities | COMPONENT | 1 |
| LP134227-0 | How much difficulty do you currently have taking care of complicated tasks like managing a checking account or getting appliances fixed | COMPONENT | 1 |
| LP134228-8 | How much difficulty do you currently have keeping important personal papers such as bills, insurance documents and tax forms organized | COMPONENT | 1 |
| LP134229-6 | How much difficulty do you currently have learning new tasks or instructions | COMPONENT | 1 |
| LP134230-4 | How much difficulty do you currently have planning an activity several days in advance, like a meal, trip, or visit to friends | COMPONENT | 1 |
| LP134231-2 | How much difficulty do you currently have getting things organized | COMPONENT | 1 |
| LP134232-0 | How much difficulty do you currently have remembering where things were placed or put away, like keys | COMPONENT | 1 |
| LP134233-8 | How much difficulty do you currently have remembering a list of 4 or 5 errands without writing it down | COMPONENT | 1 |
| LP134234-6 | How much difficulty do you currently have keeping track of time, like using a clock | COMPONENT | 1 |
| LP134235-3 | I had to read something several times to understand it in the past 7 days | COMPONENT | 1 |
| LP134236-1 | I had trouble keeping track of what I was doing if I was interrupted in the past 7 days | COMPONENT | 1 |
| LP134237-9 | I had difficulty doing more than one thing at a time in the past 7 days | COMPONENT | 1 |
| LP134238-7 | I had trouble remembering new information, like phone numbers or simple instructions in the past 7 days | COMPONENT | 1 |
| LP134239-5 | I had trouble thinking clearly in the past 7 days | COMPONENT | 1 |
| LP134240-3 | My thinking was slow in the past 7 days | COMPONENT | 1 |
| LP134241-1 | I had to work really hard to pay attention or I would make a mistake in the past 7 days | COMPONENT | 1 |
| LP134242-9 | I had trouble concentrating in the past 7 days | COMPONENT | 1 |
| LP134243-7 | I made simple mistakes more easily in the past 7 days | COMPONENT | 1 |
| LP134244-5 | Words I wanted to use seemed to be on the tip of my tongue in the past 7 days | COMPONENT | 1 |
| LP134245-2 | I had trouble remembering whether I did things I was supposed to do, like taking a medicine or buying something I needed in the past 7 days | COMPONENT | 1 |
| LP134246-0 | I walked into a room and forgot what I meant to get or do there in the past 7 days | COMPONENT | 1 |
| LP134247-8 | I had trouble remembering the name of a familiar person in the past 7 days | COMPONENT | 1 |
| LP134248-6 | I reacted slowly to things that were said or done in the past 7 days | COMPONENT | 1 |
| LP134249-4 | I had trouble forming thoughts in the past 7 days | COMPONENT | 1 |
| LP134250-2 | I had trouble getting started on very simple tasks in the past 7 days | COMPONENT | 1 |
| LP134251-0 | I had trouble making decisions in the past 7 days | COMPONENT | 1 |
| LP134252-8 | I had trouble planning out steps of a task in the past 7 day | COMPONENT | 1 |
| LP134253-6 | It was hard to control my behavior in the past 7 days | COMPONENT | 1 |
| LP134254-4 | I said or did things without thinking in the past 7 days | COMPONENT | 1 |
| LP134255-1 | I got impatient with other people in the past 7 days | COMPONENT | 1 |
| LP134256-9 | I was irritable around other people in the past 7 days | COMPONENT | 1 |
| LP134257-7 | I was bothered by little things in the past 7 days | COMPONENT | 1 |
| LP134258-5 | I became easily upset in the past 7 days | COMPONENT | 1 |
| LP134259-3 | I was in conflict with others in the past 7 days | COMPONENT | 1 |
| LP134260-1 | I felt impulsive in the past 7 days | COMPONENT | 1 |
| LP134261-9 | People told me that I talked in a loud or excessive manner in the past 7 days | COMPONENT | 1 |
| LP134262-7 | I said or did things that other people probably thought were inappropriate in the past 7 days | COMPONENT | 1 |
| LP134263-5 | I suddenly became emotional for no reason in the past 7 days | COMPONENT | 1 |
| LP134264-3 | I felt restless in the past 7 days | COMPONENT | 1 |
| LP134265-0 | It was hard to adjust to unexpected changes in the past 7 days | COMPONENT | 1 |
| LP134266-8 | I had a hard time accepting criticism from other people in the past 7 days | COMPONENT | 1 |
| LP134267-6 | I threatened violence toward people or property in the past 7 days | COMPONENT | 1 |
| LP134268-4 | Lately I had a sense of well-being | COMPONENT | 1 |