What Matters Index
A quick health check-up
During the past four weeks, how much bodily pain have you generally had?
No pain
Very mild pain
Mild pain
Moderate pain
Severe pain
How many different prescription medications are you currently taking more than three days a week?
None
1-2
3-5
More than 5
Do you think that any of your pills are making you sick?
Yes
No
Maybe, I am not sure
I am not taking any pills
During the past four weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, or sad?
Not at all
Slightly
Moderately
Quite a bit
Extremely
How confident are you that you can control and manage most of your health problems?
Very confident
Somewhat confident
Not very confident
I do not have any health problems
During the past four weeks, how much bodily pain have you generally had?
How many different prescription medications are you currently taking more than three days a week?
Do you think that any of your pills are making you sick?
During the past four weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, or sad?
How confident are you that you can control and manage most of your health problems?
sum
Summary
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
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