T.W.U. Institute for Women's Health Pioneer Project

Year 1 Personal Health Condition Questionnaire

We are interested in questions concerning you and your personal health condition. There are no correct or incorrect answers. Choose the answer which is most appropriate for you and fill in the corresponding bubble. All information is strictly confidential.

Respond by thinking about your overall situation at this point in time.

Very Poor Poor Satisfactory Good Very Good
1. Rate your overall physical condition during the past week.
2. Rate you overall quality of life during the past week.
3. Rate your emotional condition.
4. Rate your relationships and social contacts.
5. Rate your situation regarding spirituality.
6. Rate your situation regarding sexuality.
7. Rate your physical capacity.
8. Rate your occupational/career situation.
9. Rate the status of your physical environment, in general.
10. Rate your intellectual capacity, overall.
11. Rate your health, overall.
12. Rate your overall situation in life.
13. When you consider your life as a whole, are you Completely satisfied
Satisfied
Fairly satisfied
Dissatisfied
Very dissatisfied
14. When you consider your life as a whole, are you Very happy
Happy
Fairly happy
Unhappy
Very unhappy
15. How do you feel, generally, at the moment? Very well
Well
Fairly well
Not too well
Not at all well