Please click one circle for each of the 20 items:

1. How often are physical symptoms interfering with your life?
2. Are you experiencing any job or school-related problems?
3. Are you experiencing financial problems?
4. Are your social relationships affected by the illness?
5. Is sleep a problem for you because of your illness??
6. Are you happy with your family relationships?
7. Do you think negative thoughts because of your illness?
8. Are you depressed because of your illness??
9. Do you have a good relationship with your doctor(s)?
10. How much do you like yourself?
11. Are you satisfied with the activities that you are able to do?
12. Do you feel "stressed out" because of your illness??
13. Are you comfortable with the illness treatment program?
14. Are you angry because of your illness??
15. Are you fearful or anxious because of your illness??
16. Does it bother you what people say about the illness?
17. Are you able to “talk things out” with someone who is supportive?
18. Do you worry about the illness or its impact?
19. Do you use drugs or alcohol more than you should?
20. Are you hopeful about the future?

Please complete these boxes to obtain your results.

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