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* 1. In general, how would you rate your overall mental or emotional health?

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* 2. During your most recent visit, did you talk with your healthcare provider about any health questions or concerns?

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* 3. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 12 months?

  10 Best health care possible 9 8 7 6 5 4 3 2 1 0 Worst health care possible
.

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* 4. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan?

  10 Best health plan possible 9 8 7 6 5 4 3 2 1 0 Worst health plan possible
.

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* 5. During the past 4 weeks, how disruptive were your physical health or emotional problems to your normal social activities with family, friends, neighbors, or groups?

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* 6. During the past 4 weeks, how bothered did you feel by emotional problems such as feeling anxious, depressed, irritable, or sad?

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* 7. What is your age?

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* 8. What is your sexual orientation?

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* 9. What is your favorite extracurricular activity?

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* 10. Is your project with our company currently active, or has it been completed?

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