5
Sources
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Studies
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Questions
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Persons
You have indicated that you have had trouble getting (additional) health insurance. What was the outcome?
You have indicated that you have had trouble getting life insurance. What was the outcome?
Instruction: We are interested in certain things about you and your health. Please answer each question by checking the box in the indicated manner. If you are not sure how to answer a question, please give the answer that best applies to your situation. There are no wrong or right answers.
Patients sometimes report that they have the following symptoms or problems. Please indicate the extent to which you have experienced these symptoms or problems during the past week. During the past week:
Daily affairs (For example work, school, householding, family- and leisure activities)
Below are a number of statements that people often use to describe themselves. Please read each statement and then circle the appropriate number next to that statement to indicate your answer. There are no right or wrong answers. Your own impression is the only thing thing that matters.
For the following questions, please circle the number that best corresponds to your views.
