Name * Date of Birth * Choose your Medical Practice Today's Date * During the past 4 weeks how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad, or downhearted and blue? During the past 4 weeks has your physical and emotional health limited your social activities with family friends neighbors or groups During the past 4 weeks was someone available to help you if you needed and wanted help? Examples (felt nervous, lonely,got sick , needed someone to talk to or needed help caring for yourself) During the past 4 week how much bodily pain have you generally had? During the past 4 weeks what was the hardest physical activity you could do for at least 2 minutes? Can you get to places out of walking distance without help? (Can you travel alone or drive your own car?) Can you go shopping for groceries or clothes without someone's help? Can you prepare your own meals? Can you do your housework without help? Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing , or getting around the house? Can you handle your own money without help? During the past 4 weeks how would you rate your health? How have things been going for you the past 4 weeks? Are you having difficulties driving your car? Do you always fasten your seat belt when you are in a car? Have You Fallen two or more times in the past year? Are you afraid of falling? Are you a smoker? During the past 4 weeks how many drinks of wine beer or other alcoholic beverages did you have? Do you exercise for about 20 minutes 3 or more days a week? Have you been given information to help you keep track of your medicine How often to do you have trouble taking medications the way you have been told to take them? How confident are you that you can control and manage most of your health problems?

How often during the past 4 weeks have you been bothered by any of the following problems?

Falling or dizzy when standing up Sexual Problems Trouble Eating well Teeth or Dental Problems Problems using the phone Tiredness or Fatigue