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* Patient's Name

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* Today's Date

Date

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* Patient's Email

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* Patient's Date of Birth

Date

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* 1. In general, would you say your health is:

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* 2. In general, would you say your quality of life is:

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

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* 4. In general, how would you rate your mental health, including your mood and your ability to think?

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* 5. In general, how would you rate your satisfaction with your social activities and relationships?

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* 6. In general, please rate how well you carry out your usual social activities and roles.  (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)

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* 7. To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?

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