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CHAT Health Assessment Survey

 

1. During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self care, work, or recreation?

During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self care, work, or recreation?   none

1 to 2

3 to 4

5 to 6

7 to 10

11 +

2. Thinking about your mental health, which includes stress, depression and problems with emotions, for how many days during the past 30 days was your mental health not good?

Thinking about your mental health, which includes stress, depression and problems with emotions, for how many days during the past 30 days was your mental health not good?   None

1 to 2

3 to 4

5 to 6

7 to 10

11 +

3. Because of any impairment or health problems, do you need the help of others performing common tasks such as eating, dressing, moving around the home, household chores, shopping or getting around for other purposes?

Because of any impairment or health problems, do you need the help of others performing common tasks such as eating, dressing, moving around the home, household chores, shopping or getting around for other purposes?   Yes

No

4. Do you usually use any device to help you get around such as a cane, wheelchair, crutches or walker?

Do you usually use any device to help you get around such as a cane, wheelchair, crutches or walker?   Yes

No

5. How many days in the past month were you not able to work or do daily activities because of poor physical or mental health?

How many days in the past month were you not able to work or do daily activities because of poor physical or mental health?   None

1 to 2

3 to 4

5 to 5

7 to 10

11 +

6. Are you currently trying to lose weight?

Are you currently trying to lose weight?   Yes

No