Health and Wellness Survey

Age in years: (example 42, 23, etc.) 1. In general, you would say your health is? <%=mintSF1%> Excellent Very Good Good Fair Poor The following questions are about activities you might do during a typical day Does your health NOW limit you in these activities? If so. How much? 2. Moving a table, using a vacuum cleaner, bowling, or playing golf? <%=mintSF2%> Limited a lot Limited a little Not Limited 3. Climbing several flights of stairs? <%=mintSF3%> Limited a lot Limited a little Not Limited 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? 4. Accomplished less than you would like? <%=mintSF4%> Yes No 5. Were limited in the kind of work or other activities? <%=mintSF5%> Yes No During the past 4 weeks, have you had any of the following problems with your work or regular daily activities as a result of any emotional problems such as feeling depressed or anxious? 6. Accomplished less than you would like? <%=mintSF6%> Yes No 7. Didn’t do work or other activities as carefully as usual? <%=mintSF7%> Yes No 8. How much did pain interfere with work inside and outside the home? <%=mintSF8%> Not at All A little bit Moderately Quite a bit How much of the time during the past 4 weeks? 9. Have you felt calm and peaceful? <%=mintSF9%> All Most A good bit Some A little bit None 10. Did you have a lot of energy? <%=mintSF10%> All Most A good bit Some A little bit None 11. Have you felt downhearted and blue? <%=mintSF11%> All Most A good bit Some A little bit None 12. Has your physical or emotional health interfered with social activities? <%=mintSF12%> All Most Some A little None