Your Name*

Date of Birth:*

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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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