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Get Adult Day Services Client Follow-up Assessment Last Name: First Name: Date: Self-rated Health

Gn itive impairment. 1. In gen eral, wo uld you say you r health is...? 5 4 3 2 1 2. Compared to one year ago, how would you rate your health in g eneral now? Excellent Very Good Good Fair Poor 1 2 3 4 5 Much Better Now Somewhat Better Now About the Same Somewhat Worse Now Much Worse Now 3. How much bodily pain have you had during the past 4 weeks? 1 2 3 4 5 None Very M ild Mod erate Severe Very Severe How true or false is ea.

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