During the past four weeks, how much energy did you have?

How much physical pain have you had during the past four weeks?

Have you experienced a major setback including illness, accident or other event?

Do any of the following conditions limit your ability to participate as much as you would like in all activities?

Compared to other people your age, how would you rate health overall?

Compared to one year ago, how would you rate health?

Do you meet with your physician at least once a year for a check-up and any recommended medical tests?

In the past year, have you been seen by an emergency room doctor?

During the past six months, have your physical activity levels changed?

Please add any additional comments about your Physical wellness: