Ohio: New Patient Questionnaire

Welcome to Healing Family Functional Medicine

This questionnaire was designed to effectively evaluate patients, create personalized care plans, and track superior health outcomes over time. Depending on your answers, this questionnaire is 13 to 16 pages long and will ask questions from conception to now. You can save your progress at any time. Before getting started, we recommend having digital copies of your insurance card and pertinent medical records, bottles/labels of medications/supplements, and contact information for your primary care physician or referring physician. Having these items ready will allow for a quick and easy experience. Please read each question thoroughly and answer to the best of your ability.
Patient Registration
Today's Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Age*
Weight*
Height *
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number*
Home Phone Number (optional)
.
Patient or Parent/Guardian E-mail*
Patient Weight (lbs)*
Patient Height (feet and inches)*
Gender Assignment at Birth *
Gender Identity
Preferred Pharmacy Name: *
Preferred Pharmacy Phone: *
Please enter a valid phone number.
How did you hear about us?*
Please provide the name and phone number of the referring physician
Please provide the name of the friend/family member you were referred by

First NameLast Name
Responsible Party (Payments)
For all virtual visits (excluding group health), we will send a text message after your visit to collect payment. Please note that payment is due at the time of service. Please specify who this text should be sent to: *
Please provide the name and mobile phone number for the individual responsible for payments:*
Please provide the name and mobile phone number for the individual responsible for payments:*
example@example.com
Authorized Representative (Patient Portal)

Our patient portal allows you to securely access your health information, view test results, and communicate with our team—all in one convenient place.
Who will be using the patient portal?
Name of parent/guardian

First NameLast Name
Birth date of parent/guardian

MonthDayYear
Date
Email of parent/guardian
example@example.com
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.

Billing Policy

Healing Family Functional Medicine does not accept any form of medical insurance including Medicare or Medicaid. However, we can provide you with an itemized superbill containing ICD-10 diagnostic codes and CPT procedure codes at the end of your consultation if requested. You can file this with your insurance company to request reimbursement. Reimbursement is not guaranteed and is dependent on your insurance plan/deductible. We do not assist with insurance reimbursement or prior authorization outside of providing you with the superbill. Unfortunately, we do not accept Care Credit, as they require practices to follow legal requirements related to routine health maintenance. Health maintenance includes services such as vaccinations, mammograms, age-related bone density scans, etc. These services are provided by your Primary Care Physician and do not fall under the scope of Functional Medicine. If applicable, you can use your flexible spending accounts (FSA) and health savings accounts (HSA) for our services. A letter of medical necessity for FSA/HSA can be provided to you upon request. Generally, we will try to use your insurance plan for lab tests and prescription medications when possible. It is the responsibility of the patient to check for insurance coverage for labs when applicable. We can provide a letter of medical necessity for labs, but we do not perform prior authorization. Supplements through Fullscript are not billable to insurance. We do not perform prior authorizations for supplements. We can provide a letter of medical necessity for supplements upon request if you wish to send this to your insurance company to request reimbursement, or for your flexible spending account.
Appointment Fees

15-minute phone consultation: Complimentary. This is a “meet-and-greet” designed to give patients a chance to discuss their health goals and learn more about our approach. Please note that we cannot diagnose or treat during this call.

Initial evaluation: 60 minutes, $500. This includes a comprehensive medical history review, health discussion, goal setting, and ordering of any necessary tests.

Initial follow-up: 45 minutes, $375. We will review your test results and make any necessary changes to your treatment plan.

Subsequent follow-ups: 30 minutes, $250. These are routine check-ins to assess your progress. Additional tests and adjustments to your plan can be made during these visits.

Longer appointments: Available upon request. Please note that appointments running over time will incur an additional fee of $125 per 15 minutes.

NeurOptimal® NeuroFeedback: $89 per session. NeurOptimal is an optional service and can be scheduled independently — you do not need to be an established patient to book these sessions.
Submitting Payments:

For virtual visits: After your appointment you will recieve a text message with a secure link to payment. Payments are due immediately following the appointment. If you do not get a link to payment, or have difficulty accessing the link, please call our office at 216-440-5559 to submit payment by phone.

For in-person visits: Payment will be collected in the office at the time of service.
I understand and agree to the billing policy and terms: Signature*
Today's Date*

MonthDayYear
Date
Insurance Information
Please upload a copy of your insurance card

Cancelof

Privacy Policy

HEALING FAMILY FUNCTIONAL MEDICINE, LLC Policy and Procedure HIPAA/PRIVACY Notice of Privacy Practices Effective 1/5/2023
NOTICE OF PRIVACY PRACTICES

THIS NOTICE OF PRIVACY PRACTICES (“NOTICE”) DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY.

ABOUT THIS NOTICE
This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates, and our Business Associates’ subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO), and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services. We are required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify affected individuals following a breach of their unsecured health information.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, our staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice,
and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information
to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital
admission.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. If we use or disclose your protected health information for fundraising activities, we will provide you the
choice to opt out of those activities. You may also choose to opt back in.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements,
legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object, unless required by law. Without your authorization, we are expressly prohibited from using or disclosing your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes. You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS
The following are statements of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information (fees may apply) – Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or electronic format. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality. You have the right to request a restriction of your protected health information – This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to your requested restriction except if you request that the physician not disclose protected health information to your health plan with respect to healthcare for which you have paid in full out of pocket. You have the right to request to receive confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You have the right to request an amendment to your protected health information – If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14,2003, or six years prior to the date of the request. You have the right to receive notice of a breach – We will notify you if your unsecured protected health information has been breached. You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We will also make available copies of our new notice if you wish to obtain one. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment.

COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide
by the terms of the notice currently in effect. If you have any questions in reference to this form, please speak with Dr. Patel or email us at smpatel@HealingFamilyFunctionalMedicine.com

Please sign the accompanying “Acknowledgment” form. Please note that by signing the Acknowledgment form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.
Today's Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Birth Date

MonthDayYear
Patient Signature: Signature*
Authorized Personal Representative

First NameLast Name
Authorized Personal Representative Signature: Signature
FOR USE BY Healing Family Functional Medicine, LLC. PERSONNEL ONLY (complete if patient acknowledgement is not obtained).

An Acknowledgment of Receipt of Notice of Privacy Practices was not received because:
______ Patient refused to sign Acknowledgment
______ Unable to gain signed Acknowledgment due to communication / language or another barrier
______ Patient was unable to sign Acknowledgment due to emergency treatment situation
______ Other (please indicate reason): __________________________________

Signature of Healing Family Functional Medicine Representative:

__________________________________________________

Date:

__________________________________________________

OPTIONAL: Ohio HIPAA Privacy Authorization Form

**Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)** The purpose of this form is to improve care coordination for patients across multiple providers by making it easier to securely share protected health information. This allows you to specify what medical practitioners/practices you wish to share information with, for how long you wish to approve this action, and what information can/cannot be shared.
1) Authorization: I authorize Healing Family Functional Medicine to use and disclose the protected health information described below to:
Individual seeking the information (i.e., Primary Care Physician's Name)
Practitioner's Phone Number
Please enter a valid phone number.
Practitioner's Fax Number
Please enter a valid phone number.
Effective Period: This authorization for release of information covers the period of health care from:

MonthDayYear
Start Date
Until:

MonthDayYear
End Date
OR

All past, present, and future periods
3) I authorize the release of my complete health record including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse

(Check to authorize)
OR- I authorize the release of my complete health record with the exception of the following information:

Mental  health  recordsCommunicable  diseases  (including  HIV  and  AIDS)Alcohol/drug  abuse  treatmentOther (Please specify below)
Other Exceptions:
4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
5. This authorization shall be in force and effect until the date indicated below, at which time this authorization expires:

MonthDayYear
Date
6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Name of patient or personal representative:

First NameLast Name
Relationship to patient:
Signature: Signature

Informed Consent: Diagnosis & Treatment

The intention of this consent form is to help patients, clients and authorized representatives become better informed so that they may give or withhold consent to undergo diagnosis and treatment after having an opportunity to discuss health concerns, including potential benefits and risk, and treatment alternatives. I (Patient or authorized guardian or representative, will now be referred as “patient or representative”), acknowledge the opportunity to read and inquire about this consent and all the items addressed herein and hereby authorize Seema M. Patel, MD, MPH and staff (hereafter referred to as clinician), in accordance and within the scope and limits of their clinical license to perform or recommend any of the following procedures and or treatments:
Please mark the items you agree to if recommended:

1) Common Diagnostic Procedures: laboratory, x-ray, radiography, etc.2) Alternative Diagnostic Procedures including diagnostic methods, functional laboratory testing, and devices that may fall outside of the “conventional standard of care”.3) Medical Nutrition: therapeutic nutrition, nutritional supplementation, and intramuscular vitamin, mineral, amino acid, lipid, phytonutrient and metabolite precursor and or other injections as permitted by licensure.4) Botanical Medicine: medicinal herbs and plant derivatives prescribed as loose tea, capsules, tablets, creams, suppositories, etc.5) Lifestyle and Wellness counseling: to promote improved wellness through lifestyle strategies including recommendations for dietary changes, sleep, exercise, stress management, work life balance, self-care and developing and nurturing healthy relationships. This excludes specific treatment for known or suspected mental illness.6) Intravenous therapies: will refer to another facility for high doses of vitamins, minerals, amino acids, lipid, botanicals and other nutrients (only if needed).7) Our physician will refer you to our dietician (with whom we work closely) for therapeutic nutrition, food plan counseling and monitoring as needed.8)Our physician will refer to our health coach for lifestyle education, sleep management, stress management, and exercise/movement counseling and monitoring under the supervision of your physician.
Signature: Signature
Date

MonthDayYear
Date

Functional Medicine Lab Testing

The purpose of functional medicine laboratory testing is to evaluate nutrition, biochemical, and or physiological imbalance and to determine the need for medical referral and treatment. These lab tests are not intended to DIAGNOSE disease. We use conventional lab tests as well as functional medicine laboratory testing. Functional medicine assessments are designed to assist your doctor in finding the underlying causes of your condition. Functional medicine has evolved through the efforts of scientists and clinicians in the fields of clinical nutrition, molecular biology, biochemistry, physiology, conventional medicine and a wide array of scientific disciplines. Functional medicine evaluates the body as a whole, with special attention to the relationship of one body system to another and the nutrient imbalances and toxic overload that may adversely affect these relationships. Conventional healthcare providers may or may not agree with the necessity for –or our interpretation of—these tests. If you have any questions, please discuss with your physician/provider.
I understand and agree to the terms: Signature*
Date*

MonthDayYear
Date

	Mother	Father	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather
Heart disease
Stroke
Diabetes
Hypertension
Dementia
Multiple Sclerosis
Parkinson’s
Autoimmune
Blood clots
Cancer
Asthma
Food or environmental allergies
OTHER

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Headaches
Faintness
Dizziness
Insomnia

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Watery/Itchy eyes
Swollen, reddened, or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Itchy ears
Earaches/infections
Drainage from ears
Ringing in ear, hearing loss

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Stuffy Nose
Sinus Problems
Hay fever
Sneezing attacks
Excessive mucus formation

Welcome to Healing Family Functional Medicine

Patient Registration

Responsible Party (Payments)

Authorized Representative (Patient Portal)

Emergency Contact

Billing Policy

Privacy Policy

OPTIONAL: Ohio HIPAA Privacy Authorization Form

Informed Consent: Diagnosis & Treatment

Functional Medicine Lab Testing

Medical History

Covid-19

Vaccination Status

Patient Timeline

Prenatal History

Childhood History

Adult Life

Women's Health

Nutrition

Lifestyle

Section 7: Environmental Health

Medical Symptom/Toxicity Questionnaire (MSQ)

ADVERSE EVENTS QUESTIONNAIRE

Promis

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chronic coughing
Gagging, frequent throat clearing
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chest Pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Feeling of weakness or tiredness
Pain or aches in muscles

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Compulsive eating

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Poor memory
Confusion poor comprehension
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Poor concentration
Poor physical coordination

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

	Medication Name	Strength/dose	Frequency	Start Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

	Allergen	Reaction	Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

	Health Concerns
1
2
3

	Yes	No
In childhood, did a parent or adult in the household often swear at you, insult you, put you down or humiliate you?
In childhood, did a parent or adult in the household often push, slap, grab, or throw something at you or hit you hard enough to leave marks?
In childhood, did an adult or person older than you ever touch, fondle, or have you touch their body in a sexual way?
In childhood, did you often feel that no one in your family loved you or thought you were important or special? And/Or your family didn't look out for each other, did not feel close to one another, or support each other?
In childhood, did you often feel that you didn't have enough to eat, had to wear dirty clothes, or had no one to protect you? And/or your parents were drunk or high to take care of you?
In childhood, did you lose a parent to divorce, abandonment, or other reason?
In childhood, did your mother or stepmother push, slap or grab you, or threaten you with a gun or knife?
In childhood, did you live with anyone who was a problem drinker or used street drugs?
In childhood, did anyone in the household go to prison?
In childhood, was a household member depressed or mentally ill or attempt suicide?

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Frequent illness
Frequent or urgent urination
Genital itch or discharge

	Yes	No
As an adult, did a spouse, significant other, or another adult often swear at you, insult you, put you down or humiliate you?
As an adult, did a spouse, significant other or adult often push, slap, grab, or throw something at you or hit you hard enough to leave marks?
As an adult, did a spouse, significant other, or another adult ever touch, fondle, force themselves on you or have you touch their body in a sexual way?
As an adult, have you often felt (or feel) that your spouse or significant other did not love you, or feel that you are not important or special?
As an adult, have you often had to wear dirty clothes, or feel that you have no one to protect you? And/or your spouse/significant other was too drunk or high to take care of the family, finances, and/or household responsibilities?
As an adult, did you lose a spouse, significant other, child, or other important person in your life through divorce, abandonment, death or other reason? Or have you been a caretaker of an aging parent, ill spouse or child, or special needs person?
As an adult, did your spouse, significant other, or other adult ever push, slap or grab you, or threaten you with a gun or knife? Or have you been a victim or bystander of a violent crime?
As an adult, have you lived with anyone who was a problem drinker or used street drugs?
As an adult, has anyone in your household go to prison?

	Without any difficulty	With a little difficulty	With some difficulty	With much difficulty	Unable to do
Are you able to do chores such as vacuuming or yard work?
Are you able to go up and down stairs at a normal pace?
Are you able to go for a walk of at least 15 minutes?
Are you able to run errands and shop?

	Never	Rarely	Sometimes	Often	Always
I felt fearful
I found it hard to focus on anything other than my anxiety
My worries overwhelmed me
I felt uneasy

	Never	Rarely	Sometimes	Often	Always
I felt worthless
I felt helpless
I felt depressed
I felt hopeless

	Not at all	A little Bit	Somewhat	Quite a bit	Very much
I feel fatigued
I have trouble starting things because I am tired
How run-down did you feel on average?
How fatigued were you on average?

	Not at all	A little bit	Somewhat	Quite a bit	Very much
My sleep was refreshing
I had a problem with my sleep
I had difficulty falling asleep

	Never	Rarely	Sometimes	Usually	Always
I have trouble doing all of my regular leisure activities with others
I have trouble doing all of the family activities that I want to do
I have trouble doing all of my usual work (include work at home)
I have trouble doing all of the activities with friends that I want to do .

	Not at all	A little bit	Somewhat	Quite a bit	Very much
How much did pain interfere with your day to day activities?
How much did pain interfere with work around the home?
How much did pain interfere with your ability to participate in social activities?
How much did pain interfere with your household chores?