HrQol Questionaire

Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?


Number of days:

Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?


Number of days:

If you answered “none” to questions 2 and 3, write skip on question 4 below: During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?


Number of days:

Instructions: These next questions are about physical, mental, or emotional problems or limitations you may have in your daily life.

Are you LIMITED in any way in any activities because of any impairment or health problem?

Yes

Activity Limitations Module

If you said no to the previous question, please answer none to all the questions 6-9.

Activity Limitations Module

If you said no to the previous question, please answer none to all the questions 6-9.

For HOW LONG have your activities been limited because of your major impairment or health problem? (Days/weeks/months/years)

Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

Yes

During the past 30 days, for about how many days did PAIN make it hard for you to do your usual activities, such as self-care, work, or recreation?


Number of days:

During the past 30 days, for about how many days have you felt SAD, BLUE, or DEPRESSED?


Number of days:

During the past 30 days, for about how many days have you felt WORRIED, TENSE, or ANXIOUS?


Number of days:

During the past 30 days, for about how many days have you felt you did NOT get ENOUGH REST or SLEEP?


Number of days:

During the past 30 days, for about how many days have you felt VERY HEALTHY AND FULL OF ENERGY?


Number of days:

What race/ethnicity do you identify as?

If you picked please specify, answer below. If not skip.

Please leave the name of your illness (Optional)

Please leave your email if you are interested in a further survey. (optional)

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