The Duke

Instructions:
Here are some questions about your health and feelings. Carefully select your best answer. You should answer the questions in your own way. There are no right or wrong answers.









TODAY would you have any physical trouble or difficulty:




DURING THE PAST WEEK: How much trouble have you had with:







DURING THE PAST WEEK: How often did you:




DURING THE PAST WEEK: How often did you:




The questions in this document are derived from the Duke which is a copyrighted work as listed below. No questions have been altered. The form was reformatted for ease of use. Copyright © 1989-2017 by the Department of Community and Family Medicine, Duke University Medical Center, Durham, N.C., USA.