Name
*
First Name
Last Name
Age
*
18 or under
19-28
29-39
40-55
56-76
77 or over
In the past month, have you experienced any of the following symptoms? (Check all that apply)
*
Compared to previous years, do you feel that your overall sense of well-being has changed?
*
Improved
Stayed the same
Worsened
On a scale of 1-10, how would you rate your overall physical health? (1 = Poor, 10 = Excellent)
*
1
2
3
4
5
6
7
8
9
10
On a scale of 1-10, how would you rate your overall mental and emotional health? (1 = Poor, 10 = Excellent)
*
1
2
3
4
5
6
7
8
9
10
In the past month, have you experienced urine leakage in any of the following situations?
*
Has urine leakage or pelvic discomfort affected your ability to participate in activities you enjoy?
*
On a scale of 1-10, how much does pelvic discomfort or urine leakage impact your daily life? (1 = No impact, 10 = Severe impact)
*
1
2
3
4
5
6
7
8
9
10
How often do you feel limited by any physical health symptoms (such as joint pain, fatigue, or muscle weakness) in performing your daily activities?
*
Rarely or never
Occasionally
Frequently
Constantly
Over the past two weeks, how often have you been bothered by any of the following problems?
*
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself, or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading or watching TV
Moving or speaking so slowly that other people could have noticed
Thoughts that you would be better off dead or of hurting yourself in some way
If you answered “More than half the days” or “Nearly every day” to any question above, would you be open to receiving additional resources or support?
*
Yes
No
Not sure
What is your single most pressing health or wellness concern that you would like help addressing?
*
Do you have any additional comments or concerns regarding your health that were not covered in this questionnaire?
*
