Salud Integral Treatment procedures

Quality of Life Questionnaire

Please complete the questionnaire below as required.
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Optionally, you may download, complete and return to us this pdfPDF version of the questionnaire.
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Please enter the patient's name
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Below is a list of statements that others with your illness have found to be important. By checking one (1) number per line, please indicate how true each statement has been for you during the past 7 days.

PHYSICAL WELL BEING

0=Not at all  1=A little bit  2=Some what  3=Quite a bit  4=Very Much

Please make a selection
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Please make a selection

EMOTIONAL WELL BEING

0=Not at all  1=A little bit  2=Some what  3=Quite a bit  4=Very Much

Please make a selection
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Please make a selection

SOCIAL/FAMILY WELL BEING

0=Not at all  1=A little bit  2=Some what  3=Quite a bit  4=Very Much

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FUNCTIONAL WELL BEING

Please make a selection
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QUALITY OF LIFE SCALE

On a scale of 0 to 10, with 0 being such poor quality of life that it would not be worth continuing to live, and 10 being the best quality of life you have ever had, at what number would you rate the following?
Please enter a number from 0 to 10
Please enter a number from 0 to 10
Please enter a number from 0 to 10

PAIN SCALE

Please enter a number between 0 and 10
Using the same scale, what has been your average pain level in:
Please enter a number between 0 and 10
Please enter a number between 0 and 10
Please enter a number between 0 and 10
Please make a selection
Please enter your normal weight here
Please enter your current weight here
Please list all medications you are currently taking below
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