Please respond to each question or statement by marking one box per row.
| Never | Rarely | Sometimes | Often | Always | ||
| EmotionalImpactQ11 | In the past 7 days, how often did you feel completely hopeless because of your health? ………………………………….. |
5 |
4 |
3 |
2 |
1 |
| Not at all | A little | Somewhat | Quite | Very | ||
| EmotionalImpactQ12 | In the past 7 days, how lonely did you feel because of your health problems? .. |
5 |
4 |
3 |
2 |
1 |
| EmotionalImpactQ16 | In the past 7 days, how depressed were you about your health problems? ……………………………………. |
5 |
4 |
3 |
2 |
1 |
| Not at all | A little bit | Somewhat | Quite a bit | Very much | ||
| EmotionalImpactQ9 | In the past 7 days, how much did you worry about getting sick? …………………. |
5 |
4 |
3 |
2 |
1 |
| Never | Rarely | Sometimes | Often | Always | ||
| EmotionalImpactQ17 | In the past 7 days, how often were you very worried about needing to go
to the hospital?………………………………… |
5 |
4 |
3 |
2 |
1 |