Quality of Life

Patient Quality of Life Survey

Please take several minutes to answer these questions so we can help you get better. (Please check all that apply)

1. How have you taken care of your health in the past?

2. How did the previous method(s) work out for you?

3. How have others been affected by your health condition?

4. What are you afraid this might be (or beginning) to affect (or will affect)?

5. Are there health conditions you are afraid this might turn into?

6. How has your health condition affected your job, relationships, finances, family, or other activities? Please give examples:

7. What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.). Give 3 examples:

8. What are you most concerned with regarding your problem?

9. Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specific.

10. What would be different/better without this problem? Please be specific.

11. What do you desire most to get from working with us?

12. What would that mean to you?

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