Accomplished less than you a like 1 2 3 4 5 Were limited in the kind of b work or other activities 1 2 3 4 5 During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? All of Most of Some of A little of None of the time the time the time the time the time Accomplished less than you a would like 1 2 3 4 5 Did work or other activities b less carefully than usual 1 2 3 4 5 During the past 4 weeks, how much did the pain interfere with your work (including both work outside the home and housework)? Not at all A little bit Moderately Quite a bit Extremely 1 2 3 4 5 These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks… All of Most of Some of A little of None of the time the time the time the time the time Have you felt calm and a peaceful? 1 2 3 4 5 Did you have a lot of energy? b 1 2 3 4 5 Have you felt downhearted c and depressed? 1 2 3 4 5
a Accomplished less than you like 1 2 3 4 5 b Were limited in the kind of work or other activities 1 2 3 4 5 During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? All of the time Most of the time Some of the time A little of the time None of the time a Accomplished less than you would like 1 2 3 4 5 b Did work or other activities less carefully than usual 1 2 3 4 5 During the past 4 weeks, how much did the pain interfere with your work (including both work outside the home and housework)? Not at all A little bit Moderately Quite a bit Extremely 1 2 3 4 5 These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks… All of the time Most of the time Some of the time A little of the time None of the time a Have you felt calm and peaceful? 1 2 3 4 5 b Did you have a lot of energy? 1 2 3 4 5 c Have you felt downhearted and depressed? 1 2 3 4 5
sather-clinic-dancer-intake-form-15.docx