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Patient's Name

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Patient's Date of Birth

Date

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Today's Date

Date

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

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2. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

  Yes, limited a lot Yes, limited a little No, not limited at all
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
b. Climbing several flights of stairs

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3. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

  No, none of the time Yes, a little of the time Yes, some of the time Yes, most of the time Yes, all of the time
a. Accomplished less than you would like
b. Were limited in the kind of work or other activities

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4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

  No, none of the time Yes, a little of the time Yes, some of the time Yes, most of the time Yes, all of the time
a. Accomplished less than you would like
b. Didn't do work or other activities as carefully as usual

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5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

 
50% of survey complete.

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