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Patient Health Assessment

Over the past 2 weeks, how often have you been bothered by any of the following problems?

Not At All
Several Days
More Than Half the Days
Nearly Every Day
Not At All
Several Days
More Than Half the Days
Nearly Every Day
Not At All
Several Days
More Than Half the Days
Nearly Every Day
Not At All
Several Days
More Than Half the Days
Nearly Every Day
Not At All
Several Days
More Than Half the Days
Nearly Every Day
Not At All
Several Days
More Than Half the Days
Nearly Every Day
Not At All
Several Days
More Than Half the Days
Nearly Every Day
Not At All
Several Days
More Than Half the Days
Nearly Every Day
Not At All
Several Days
More Than Half the Days
Nearly Every Day
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

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