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Mais...
Seeking your feedback
Name
Are you concerned about how your recovery is progressing?
0 (No concerns)
1
2
3
4
5 (Extremely concerned)
Do you feel in control of your recovery?
0 (Complete control)
1
2
3
4
5 (No control)
Is your injury stopping you from completing your day-to-day activities?
0 (Not at all)
1
2
3
4
5 (Unable to complete activities)
Is your mental health being impacted by your injury?
0 (Not at all)
1
2
3
4
5 (Extremely impacted)
Are you concerned that you may increase your symptoms when currently performing activities?
0 (Not at all)
1
2
3
4
(Extremely concerned)
Are your sleep, energy levels and appetite being affected by your injury?
0 (Not at all)
1
2
3
4
5 (Extremely affected)
Compared to before to your injury, how is your personal and social life currently being impacted ? (i.e. relationships with family and friends, social engagements, interacting in the community)
0 (Not at all)
1
2
3
4
5 (Extremely impacted)
How difficult is it for you to complete things you need to do like chores around the house, showering, getting dressed and driving etc.?
0 (Not at all)
1
2
3
4
5 (Extremely difficult)
What did you enjoy doing before your injury that you'd like to start doing again? Any ideas of how we can help?
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Thanks very much for taking the time.