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ADAPT Workshop Health Survey

We will email you a copy of the survey results.
Please respond to each item by marking one box per row
ExcellentVery GoodGoodFairPoor
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.)
CompletelyMostlyModeratelyA LittleNot 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?

In the Past Seven Days

Please answer the questions below considering how you've felt in just the past week.
How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?
NoneMildModerateSevereVery Severe
How would you rate your fatigue on average?
0 (None)12345678910 (Worst)
How would you rate your pain on average?