Satisfaction with Social Role	Not at all	A little bit	Somewhat	Quite a bit	Very much
In the past 7 days…
I am satisfied with how much work I can do (include work at home)	□ 1	□ 2	□ 3	□ 4	□ 5
I am satisfied with my ability to work (include work at home)	□ 1	□ 2	□ 3	□ 4	□ 5
I am satisfied with my ability to do regular personal and household responsibilities	□ 1	□ 2	□ 3	□ 4	□ 5
I am satisfied with my ability to perform my daily routines	□ 1	□ 2	□ 3	□ 4	□ 5