Optional Health Assessment Modules Form Page 10
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27UR Number:
Surname:
Given name:
Date of birth:
(Please fill in if no label available)
NOT AT ALL
A LITTLE
A MODERATE
VERY MUCH
AN EXTREME
AMOUNT
AMOUNT
6. To what extent do you feel your life to be
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meaningful?
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7. How well are you able to concentrate?
8. How safe do you feel in your daily life?
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9. How healthy is your physical environment?
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The following questions ask about how completely you experience or were able to do certain things in the last two weeks.
NOT AT ALL
A LITTLE
MODERATELY
MOSTLY
COMPLETELY
10. Do you have enough energy for
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everyday life?
11. Are you able to accept your bodily
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appearance?
12. Have you enough money to meet your
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needs?
13. How available to you is the informa-
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tion that you need in your day-to-day
life?
14. To what extent do you have the op-
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portunity for leisure activities?
VERY POOR
POOR
NEITHER
GOOD
VERY GOOD
POOR NOR
GOOD
15. How well are you able to get around?
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FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
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Parent category: Medical