Perception of Wellness Survey

  • GENERAL HEALTH





  • LIMITATIONS OF ACTIVITIES

    The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?




















  • PHYSICAL HEALTH PROBLEMS

    During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?








  • SOCIAL ACTIVITIES

    During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?








  • PAIN





  • ENERGY AND EMOTIONS

    These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

    How much of the time during the past 4 weeks . . .


















  • SOCIAL ACTIVITIES



  • GENERAL HEALTH

    How TRUE or FALSE is each of the following statements for you?








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