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* 1. Overall attitude

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* 2. How sad/depressed are you?

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* 3. How frustrated/irritable/angry are you?

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* 4. How overwhelmed are you?

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* 5. How worried or anxious are you?

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* 6. What is your sleep quality?

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* 7. How much sleep are you getting?

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* 8. How much physical activity are you getting?

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* 9. How alone and isolated do you feel

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* 10. How much family engagement are you experiencing at home or virtually?

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* 11. How socially connected do you feel?

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* 12. How much are you reaching out to help others?

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* 13. What is your primary source of media?

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* 14. How much media are you exposed to?

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* 15. Are you able to focus positively on the future when the pandemic is over?

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* 16. Please add any additional comments you have about how you are impacted by the events of the pandemic.

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* 17. First and Last Name

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* 18. Date

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