* 1. In general would you say your health is?

* 2. Compared to one year ago, how would you rate your health in general?

* 3. Do you have any long term illness, health problem or disability which limits your daily activities?

* 4. Which of the following health problems or conditions have you experienced in the last 3 months?

  No Problem Minimal Problem Mild Problem Moderate Problem Moderately Severe Problem Severe Problem Very Severe Problem
Asthma
Eczema
Allergies
Cough/cold
Depression/Anxiety

* 5. How many times have you visited the following services in the last 3 months?GP - 

  Not at All 1-2 times 3-4 times 5-6 times 7-8 times 9-10 times 10+ times
GP - fixed appointment
GP - in an emergency
Hospital - fixed appointment
A&E

* 6. Below are some statements about your thoughts and feelings.  Please tick the box that best describes your experience of each over the last 2 weeks?

  None of the time Rarely Some of the time Often All of the time
I've been feeling optimistic about the future
I've been feeling useful
I've been feeling relaxed
I've been feeling interested in other people
I've had energy to spare
I've been dealing with problems well
I've been thinking clearly
I've been feeling good about myself
I've been feeling close to other people
I've been feeling confident
I've been able to make up my own mind about things
I've been feeling loved
I've been interested in new things
I've been feeling cheerful

* 7. What is Your Gender?

* 8. What is Your Age?

* 9. What is your Ethnicity?

* 10. Postcode

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