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Patient Reported Outcome(PRO)
What is your age?
What is your gender?
How often do you use medical service/medication, etc?
What is your treatment Currently?
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Under each heading, please tick the ONE box that best describes your health TODAY.
MOBILITY
I have no problems in walking about
I have some problems in walking about
I am confined to bed
SELF-CARE
I have no problems with self-care
I have some problems washing or dressing myself
I am unable to wash or dress myself
USUAL ACTIVITIES
I have no problems with performing my usual activities
I have some problems with performing my usual activities
I am unable to perform my usual activities
PAIN / DISCOMFORT
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort
ANXIETY / DEPRESSION
I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed
We would like to know how good or bad your health is TODAY.
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Should be Empty: