You're almost done with your General Health Assessment
Just answer each question by checking the box with the best response
In general, would you say your health is
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Excellent
Very good
good
fair
poor
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In general, would you say your quality of life is?
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Excellent
Very Good
Good
Fair
Poor
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In general, how would you rate your physical health?
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Excellent
Very Good
Good
Fair
Poor
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In general, how would you rate your mental health, including your mood and your ability to think?
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Excellent
Very Good
Good
Fair
Poor
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In general, how would you rate your satisfaction with your social activities and relationships?
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Excellent
Very Good
Good
Fair
Poor
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In general, please rate how well you carry out your usual social activities and roles. ( This includes activities and responsibilites as a parent, child, spouse, employee, friend, etc.)
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Excellent
Very Good
Good
Fair
Poor
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To what extent are you able to carry out your everyday physical activitities such as walking,climbing stairs, carrying groceries, or moving a chair?
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Excellent
Very Good
Good
Fair
Poor
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How often have you been bothered by emotional problems such as feeling anxious,depressed or irritable?
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Excellent
Very Good
Good
Fair
Poor
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How would you rate your fatigue in average?
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Excellent
Very Good
Good
Fair
Poor
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How would you rate your pain on average?
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0(no pain)
1
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9
10 (Worst pain)
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I agree that the answers to the questions provided are true to the best of my knowledge.
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Done
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