| Springfield College

I would like to enroll in the

Walk With Ease group program

Walk With Ease self-directed program

I'm not sure which Walk With Ease program is right for me

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone number

Age

Gender

Do you have any health conditions? (Please check all that apply)

Arthritis

High blood pressure

Diabetes

Asthma

Other

Your Health and Well-Being

We’d like to know more about your health and well-being, please respond to each question or statement below by marking one box per row. This is optional but helpful information.

Questions	Poor	Fair	Good	Very Good	Excellent
In general, would you say your health is:	Poor	Fair	Good	Very Good	Excellent
In general, would you say your quality of life is:	Poor	Fair	Good	Very Good	Excellent
In general, how would you rate your physical health?	Poor	Fair	Good	Very Good	Excellent
In general, how would you rate your mental health, including your mood and your ability to think?	Poor	Fair	Good	Very Good	Excellent
In general, how would you rate your satisfaction with your social activities and relationship?	Poor	Fair	Good	Very Good	Excellent
In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)	Poor	Fair	Good	Very Good	Excellent
To what extent are you able to carry out your everyday physical activities? This includes walking, climbing stairs, carrying groceries, or moving a chair.	Poor	Fair	Good	Very Good	Excellent

Questions	Never	Rarely	Sometimes	Often	Always
In the past 7 days, how often have you been bothered by emotional problems, such as feeling anxious, depressed or irritable?	Never	Rarely	Sometimes	Often	Always

Questions	None	Mild	Moderate	Severe	Very severe
In the past 7 days, how would you rate your fatigue, on average?	None	Mild	Moderate	Severe	Very severe

In the past 7 days, how would you rate your pain on average?

0 is no pain; 10 is worst pain imaginable.