| Example: | Your health is: |
| Excellent ... [ ] Good ... [ ] Fair ... [ ] Poor ... [ ] | |
| Your health is: | |
| Excellent ........ [ ] Good ............. [ ] Fair ............... [ ] Poor .............. [ ] |
| Example: | Your health is: |
| Excellent ... [ ] Good ... [ ] Fair ... [ ] Poor ... [ ] | |
| Your health is: | |
| Excellent ........ [ ] Good ............. [ ] Fair ............... [ ] Poor .............. [ ] |