CDEs
Forms
Are you able to jump over an object that is 1 foot (30 cm) tall?
Are you able to jump over a puddle that is 3 feet (1 m) wide?
Are you able to jump 2 feet (60 cm) high?
Are you able to walk across a balance beam?
Are you able to stand on one foot with your eyes closed for 30 seconds?
Are you able to walk in a straight line putting one foot in front of the other (heel to toe) for 5 yards (5 m)?
Are you able to put your hands flat on the floor with both feet flat on the ground?
Are you able to carry a large baby (15 lbs/7 kg) out of the house to a car or taxi?
Are you able to lift and load one 50-pound (25 kg) bag of sand into a car?
Are you able to climb a 6-foot (2 m) ladder?
Are you able to push an empty refrigerator forward 1 yard (1 m)?
Are you able to carry a 50 lb (25 kg) bag of sand 25 yards (25 m)?
Are you able to pull a sled or a wagon with two children (total 100 lbs/50 kg) for 100 yards (100 m)?
Are you able to stand up from a push-up position five times quickly?
Are you able to swim laps for 30 minutes at a moderate pace?
Are you able to dance energetically for an hour?
Does your health now limit you in doing vigorous activities, such as running, lifting heavy objects, participating in strenuous sports?
Does your health now limit you in exercising regularly?
Does your health now limit you in bending, kneeling, or stooping?
Does your health now limit you in doing heavy work around the house like scrubbing floors, or lifting or moving heavy furniture?
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