ADAPT Workshop Health Survey - Kresser Institute

Email(Required)

We will email you a copy of the survey results.

Overall Wellbeing(Required)

Please respond to each item by marking one box per row

	Excellent	Very Good	Good	Fair	Poor
In general, would you say your health is:
In general, would you say your quality of life is:
In general, how would you rate your physical health?
In general, how would you rate your mental health, including your mood and your ability to think?
In general, how would you rate your satisfaction with your social activities and relationships?
In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)

Physical Activity(Required)

	Completely	Mostly	Moderately	A Little	Not At All
To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?

Please answer the questions below considering how you've felt in just the past week.

Emotions(Required)

Fatigue(Required)

Pain(Required)

	Never	Rarely	Sometimes	Often	Always
How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?

	None	Mild	Moderate	Severe	Very Severe
How would you rate your fatigue on average?

	0 (None)	1	2	3	4	5	6	7	8	9	10 (Worst)
How would you rate your pain on average?