1. I like who I am Yes, describes me exactly Somewhat describes me No, doesn't describe me at all
2. I am not an easy person to get along with Yes, describes me exactly Somewhat describes me No, doesn't describe me at all
3. I am basically a healthy person Yes, describes me exactly Somewhat describes me No, doesn't describe me at all
I give up too easily Yes, describes me exactly Somewhat describes me No, doesn't describe me at all
5. I have difficulty concentrating Yes, describes me exactly Somewhat describes me No, doesn't describe me at all
6. I am happy with my family relationships Yes, describes me exactly Somewhat describes me No, doesn't describe me at all
7. I am comfortable being around people Yes, describes me exactly Somewhat describes me No, doesn't describe me at all
8. Walking up a flight of stairs None Some A lot
9. Running the length of a football field None Some A lot
10. Sleeping None Some A lot
11. Hurting or aching in any part of your body None Some A lot
12. Getting tired easily None Some A lot
13. Feeling depressed or sad None Some A lot
14. Nervousnes None Some A lot
15. Socialize with other people (talk or visit with friends or relatives) None Some A lot
16. Take part in social, religious, or recreation activities (meetings, church, movies, sports, parties) None Some A lot
17. Stay in your home, a nursing home, or hospital because of sickness, injury, or other health problem None 1-4 Days 5-7 Days
Your Initials:
Who should receive these results? Cancel Maj. Smith, LCSW Dr. Webb
The questions in this document are derived from the Duke which is a copyrighted work as listed below. No questions have been altered. The form was reformatted for ease of use. Copyright © 1989-2017 by the Department of Community and Family Medicine, Duke University Medical Center, Durham, N.C., USA.