ABLE TO BE HEALTHY PERCEIVED BARRIERS QUESTIONNAIRE

We are interested in how easy or difficult it would be for you to go to activities in your community. For each statement, circle the number that represents how difficult it would be for you to attend an event or activity in your community. If a statement does not apply to you or if it would not be a problem for attending a health promotion program, please rate it as zero.

1. It’s difficult to get in and out of my house/apartment.	0 1 2 3
2. My neighborhood has too few curb cuts.	0 1 2 3
3. It is dangerous for me to leave my house/apartment.	0 1 2 3
4. It would take too long to get to the event.	0 1 2 3
5. Chemicals in the environment bother me.	0 1 2 3
6. The weather is often too bad to get out.	0 1 2 3
7. I have trouble reading printed materials.	0 1 2 3
8. Buildings are not accessible to me.	0 1 2 3
9. I don’t have accessible transportation.	0 1 2 3
10. I don’t have the assistive equipment that I need.	0 1 2 3
11. My disability is limiting me too much these days.	0 1 2 3
12. I have a hard time thinking and concentrating.	0 1 2 3
13. I lose control over my bowel and bladder functions.	0 1 2 3
14. My weight makes it hard to get around.	0 1 2 3
15. I get tired easily.	0 1 2 3
16. I have pain when I do too much.	0 1 2 3
17. I can’t see well enough to get around.	0 1 2 3
18. I have trouble hearing what people say.	0 1 2 3
19. I have to take time off from my job.	0 1 2 3
20. I’m too busy to take time away from other important activities.	0 1 2 3
21. I have to arrange day care for my children.	0 1 2 3
22. I take care of another family member.	0 1 2 3
23. My family does not support my getting out.	0 1 2 3
24. My daily self-care needs take too much energy.	0 1 2 3
25. I would need someone to help me.	0 1 2 3
26. My doctor would not approve of it.	0 1 2 3
27. Other important people tell me not to go out.	0 1 2 3