Quality of Life

Weight Management

    Please only complete this form if someone from the team as asked you to do so.

    Your Name*

    Date of Birth:*


    Please answer the following statements by selecting the number that best applies to you in the past four weeks. Be as honest as possible. There are no right and wrong answers.

    How would you rate your quality of life?

    1 - Very Poor2 - Poor3 - Neither Poor nor Good4 - Good5 - Very Good

    How satisfied are you with your health?

    1 - Very Dissatisfied2 - Dissatisfied3 - Neither Satisfied nor Dissatisfied4 - Satisfied5 - Very Satisfied

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    In an Emergency call 999 for health advice and reassurance call NHS24 on 111.
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