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Persons
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?
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?
These questions ask for your views about your health. This information will keep track of how you feel and how well you are able to do your usual activities. Please answer every question by marking one box. if you are unsure about how to answer, please give the best answer you can.
Please indicate for each condition whether it interferes with your activities or not.
Please fill in the questionnaire by yourself, in your own pace. You can answer the questions by checking the box/number that applies best to your situation. If you are not sure, please answer the question by choosing the answer that is closest to your situation. There are no right or wrong...
The following questions are about how you feel right now. Please choose the answer that best describes your current feeling. Do not think too long about your answer. These statements are about your personal impression. There are no wrong answers: it is opinion based.
How much does your illness affect you emotionally? (e.g. does it make you angry, scared, upset or depressed?
