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* 1. In general, how would you rate your health?

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* 2. Does your health limit activities such as moving a table, pushing a vacuum, bowling or playing golf?

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* 3. During past 4 weeks, has your physical health affected your ability or limited the kind of work or activities you are able to perform?

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* 4. During the past 4 weeks, have emotional problems affected your ability to focus at home and/or at work?

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* 5. During the past 4 weeks, did pain interfere with your normal activities at home and/or at work? 

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* 6. During the past 4 weeks, have you felt calm and peaceful?

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* 7. During the past 4 weeks, have you had a lot of energy?

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* 8. During the past 4 weeks, have you felt downhearted and low?

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* 9. During the past 4 weeks, has your health limited your social activities such as visiting friends or relatives?

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* 10. At what email address would you like to be contacted?

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