Input 2 Input how would you rate your mood? * 10 – Excellent 9 – Good 8 – Good 7 – Good 6 – Fair 5 – Fair 4 – Fair 3 – Poor 2 – Poor 1 – Poorhow would you rate your energy? * 10 – Very High 8 – High 6 – Moderate High 4 – Moderate Low 2 – Low 0 – Very Lowhow would you rate your mental functioning / clarity? * 10 – Very Good 8 – Good 6 – Moderate Good 4 – Moderately Bad 2 – Bad 0 – Very Badhow would you rate your sense of calmness? * 10 – Very Calm 8 – Calm 6 – Moderate Calm 4 – Moderate Stressed 2 – Stressed 0 – Very Stressedhow would you rate your pain? * 0 – No Pain 2 – Very Mild Pain 4 – Mild Pain 6 – Moderate Pain 8 – Severe Pain 10 – Extremely severe ImaginablePlease rate your overall sleep quality? * 0 – Terrible 1 – Poor 2 – Poor 3 – Poor 4 – Fair 5 – Fair 6 – Fair 7 – Good 8 – Good 9 – Good 10 – ExcellentChoose any number between 0 and 100 that describes your quality of life * 100 – Perfect quality of life 95 – Nearly perfect quality of life 90 85 – Very good quality of life 80 75 70 – Good quality of life 65 60 55 – Moderately good quality of life 50 45 40 – Somewhat bad quality of life 35 30 – Bad quality of life 25 20 15 – Very bad quality of life 10 5 – Extremely bad quality of life 0 – No quality of life ContinueSubmit
