Agency/Facility Program Date Completed For each box, put anin the circle that applies to you. Gender Age Primary reason for receiving Male 20 and under services Female 21-24 Emotional/Mental Health 25-34 Alcohol or Drugs 35-54 Both Emotional/Mental Health and 55-64 Alcohol or Drugs 65 and older Race Ethnicity Length of Service White Puerto Rican Less than 1 year Black/ African American Mexican 12 months to 2 years American Indian/Alaskan Other Hispanic or Latino 2 years to 5 years Native Hawaiian/ Pacific Islander Not Hispanic More than 5 years Asian Mixed Other Please read each question, assess your feelings, and circle the number on the scale that gives the best answer for you for each question. (Please circle the number) Very poor Poor Neither poor nor Good Very Good good How would you rate your 1 2 3 4 5 quality of life? (Please circle the number) Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied nor dissatisfied How satisfied are you 1 2 3 4 5 with your health? The following questions ask about how much you have experienced certain things in the last two weeks. (Please circle the number) Not at all A little A moderate Very much An extreme amount amount To what extent do you 1 2 3 4 5 feel that physical pain prevents you from doing what you need to do?
Agency/Facility Program Date Completed For each box, put anin the circle that applies to you. Gender Male Female Age 20 and under 21-24 25-34 35-54 55-64 65 and older Primary reason for receiving services Emotional/Mental Health Alcohol or Drugs Both Emotional/Mental Health and Alcohol or Drugs Race White Black/ African American American Indian/Alaskan Native Hawaiian/ Pacific Islander Asian Mixed Other Ethnicity Puerto Rican Mexican Other Hispanic or Latino Not Hispanic Length of Service Less than 1 year 12 months to 2 years 2 years to 5 years More than 5 years Please read each question, assess your feelings, and circle the number on the scale that gives the best answer for you for each question. (Please circle the number) Very poor Poor Neither poor nor good Good Very Good How would you rate your quality of life? 1 2 3 4 5 (Please circle the number) Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied How satisfied are you with your health? 1 2 3 4 5 The following questions ask about how much you have experienced certain things in the last two weeks. (Please circle the number) Not at all A little A moderate amount Very much An extreme amount To what extent do you feel that physical pain prevents you from doing what you need to do? 1 2 3 4 5
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