1. Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase?
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1
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2
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3
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4
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2. Do you have any trouble taking a long walk?
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1
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2
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3
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4
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3. Do you have any trouble taking a short walk outside of the house?
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1
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2
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3
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4
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4. Do you need to stay in bed or a chair during the day?
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1
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2
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3
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4
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5. Do you need help with eating, dressing, washing yourself, or using the toilet?
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1
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2
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3
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4
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During the past week:
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6. Were you limited in doing either your work or other daily activities?
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1
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2
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3
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4
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7. Were you limited in pursuing your hobbies or other leisure time activities?
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1
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2
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3
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4
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8. Were you short of breath?
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1
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2
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3
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4
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9. Have you had pain?
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1
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2
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3
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4
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10. Did you need to rest?
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1
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2
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3
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4
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11. Have you had trouble sleeping?
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1
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2
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3
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4
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12. Have you felt weak?
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1
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2
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3
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4
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13. Have you lacked appetite?
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1
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2
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3
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4
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14. Have you felt nauseated?
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1
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2
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3
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4
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15. Have you vomited?
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1
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2
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3
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4
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16. Have you been constipated?
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1
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2
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3
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4
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During the past week:
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17. Have you had diarrhea?
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1
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2
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3
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4
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18. Were you tired?
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1
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2
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3
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4
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19. Did pain interfere with your daily activities?
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1
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2
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3
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4
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20. Have you had difficulty in concentrating on things, like reading a newspaper or watching television?
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1
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2
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3
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4
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21. Did you feel tense?
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1
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2
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3
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4
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22. Did you worry?
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1
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2
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3
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4
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23. Did you feel irritable?
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1
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2
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3
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4
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24. Did you feel depressed?
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1
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2
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3
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4
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25. Have you had difficulty remembering things?
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1
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2
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3
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4
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26. Has your physical condition or medical treatment interfered with your family life?
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1
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2
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3
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4
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27. Has your physical condition or medical treatment interfered with your social activities?
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1
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2
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3
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4
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28. Has your physical condition or medical treatment caused you financial difficulties?
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1
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2
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3
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4
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For the following questions please circle the number between 1 and 7 that best applies to you.
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29. How would you rate your overall health during the past week?
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1 2 3 4 5 6 7
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Very poor Excellent
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30. How would you rate your overall quality of life during the past week?
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1 2 3 4 5 6 7
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Very poor Excellent
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