Client Information

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Over the last 2 weeks, how often have you been bothered by the following problems?

This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.

Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please choose only one response.

In the past 30 days, how much difficulty did you have in:

Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully, pick the answer that indicates how much you have been bothered by that problem in the last month.

Please indicate whether you’ve experienced the following concerns in the: 

Past Month, 2-12 Months Ago, More than a Year Ago, or Never