-
You think your health is
Not good
Good
Very good
-
Do you feel limited in moderate activities? (eg. moving a table, use the vacuum cleaner)
Yes, completely
Yes, partially
No
-
Do you feel limited in climbing flight of stairs?
Yes, completely
Yes, partially
No
-
Do you feel limited in the dress?
Yes, completely
Yes, partially
No
-
Do you feel limited in going to work? (Please insert your job _______________)
Yes, completely
Yes, partially
No
-
Do you feel limited in leisure activities?
Yes, completely
Yes, partially
No
-
During therapy with negative pressure did you feel
Discouraged
Sad
E nergetic
Calm
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