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  • Morristown Medical Center
    Thomas E. Reilly Heart Success Program

  • Phone: 973-971-4179

Questionnaire

This questionnaire asks for your views about your health. This information will help keep track of how you feel and how you are able to do your usual activities. If you are unsure about how to answer a question, please give the best answer you can. Please print this page, circle your answers on the questionnaire and bring your answers to your doctor:

1. In general, how would you say your health is?
  • Excellent
  • Very good
  • Good
  • Fair
  • Poor
2. Does your health now limit your participation in moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?
  • Yes, limited a lot
  • Yes, limited a little
  • No, not limited at all
3. Does your health now limit your participation in more difficult activities, such as climbing several flights of stairs?
  • Yes, limited a lot
  • Yes, limited a little
  • No, not limited at all
4. During the past four weeks, have you accomplished less than you would like at work or during other regular daily activities as a result of your physical health?
  • Yes
  • No
5. During the past four weeks, has your health limited your participation in the kind of work or other activities you usually do?
  • Yes
  • No
6. During the past four weeks, have you accomplished less than you would have liked at work or during other regular daily activities because of any emotional problems (such as feeling depressed or anxious)?
  • Yes
  • No
7. During the past four weeks, have you completed work or other activities less carefully than usual because of any emotional problems (such as feeling depressed or anxious)?
  • Yes
  • No
8. During the past four weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
  • Not at all
  • A little bit
  • Moderately
  • Quite a bit
  • Extremely
9. How often during the past four weeks have you felt calm and peaceful?
  • All of the time
  • Most of the time
  • A good bit of the time
  • Some of the time
  • A little bit of the time
  • None of the time
10. How often during the past four weeks have you had a lot of energy?
  • All of the time
  • Most of the time
  • A good bit of the time
  • Some of the time
  • A little bit of the time
  • None of the time
11. How often during the past four weeks have you felt downhearted and blue?
  • All of the time
  • Most of the time
  • A good bit of the time
  • Some of the time
  • A little bit of the time
  • None of the time
12. How often during the past four weeks has your physical or emotional health interfered with your social activities (like visiting friends, relatives, etc.)?
  • All of the time
  • Most of the time
  • A good bit of the time
  • Some of the time
  • A little bit of the time
  • None of the time
  • Morristown Medical Center
    Thomas E. Reilly Heart Success Program

  • Phone: 973-971-4179

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Morristown Medical Center

100 Madison Avenue
Morristown, NJ 07960
973-971-5000

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Affiliated Providers

Atlantic Medical Group

More than 600 community-
based health care providers.
1-800-247-9580