Step 1 of 4 25% SCALE: Not Confident at All ( 0% - 10% - 20% - 30% - 40% - 50% - 60% - 70% - 80% - 90% - 100%) Completely Confident How confident are you that you can sit in any type of chair / seat for as long as you want / need to?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you can stand for as long as you want / need to?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you can walk as long as you want / need to?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you can climb up and down the stairs?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you can get up / down from a sofa or low chair?0%10%20%30%40%50%60%70%80%90%100% How confident are you that you can get in / out of a car or bus?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you can reach above your head?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you can bend down and return to a standing position?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you can kneel down and return to a standing position?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you could carry a small box?0%10%20%30%40%50%60%70%80%90%100% How confident are you that you could carry a large box?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you can lift a box from a table?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you can lift a box from a floor?0%10%20%30%40%50%60%70%80%90%100%How confident are you that you could push or pull an object?0%10%20%30%40%50%60%70%80%90%100% Enter Your Name and Email Address to get your ResultNameEmail* This iframe contains the logic required to handle AJAX powered Gravity Forms. x