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\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13960162 \chftnsepc
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\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13960162 \chftnsep
\par }}{\*\aftnsepc \ltrpar \pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid410723 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13960162 \chftnsepc
\par }}\ltrpar \sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\footerr \ltrpar \pard\plain \ltrpar\s19\qr \li0\ri0\widctlpar
\tqc\tx4513\tqr\tx9026\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid8074696 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\field{\*\fldinst {\rtlch\fcs1 \af0
\ltrch\fcs0 \insrsid8074696 PAGE \\* MERGEFORMAT }}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid9052714 1}}}\sectd \ltrsect\linex0\endnhere\sectdefaultcl\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8074696
\par }}{\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang {\pntxta )}}
{\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8
\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\pard\plain \ltrpar
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\fs32\cf17\lang2057\langfe1033\loch\af31502\hich\af31502\dbch\af31501\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\fs36\insrsid6752554 \hich\af31502\dbch\af31501\loch\f31502 N}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\fs36\insrsid7026218
\hich\af31502\dbch\af31501\loch\f31502 CL Primary Care}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\fs36\insrsid4733039\charrsid15083790 \hich\af31502\dbch\af31501\loch\f31502 COVID-19 Recovery Questionnaire}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\fs36\insrsid4733039
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid15146835 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0
\ltrch\fcs0 \b\insrsid15146835\charrsid15146835
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\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1384\clshdrawnil \cellx1276\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3365\clshdrawnil \cellx4641
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1077\clshdrawnil \cellx5718\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4772\clshdrawnil \cellx10490\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7026218\charrsid7026218 Full Name:}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 \cell
{\*\bkmkstart PCMMeNQg4zDBSQR1ecik}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield
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Title}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 00020000140000001450434d4d654e5167347a4442535152316563696b00000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PCMMeNQg4zDBSQR1ecik}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 Full Name}}}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\bkmkend PCMMeNQg4zDBSQR1ecik} {\*\bkmkstart Text9}}{\field{\*\fldinst {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9}}}}}{\fldrslt {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid7799968 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\bkmkend Text9}\cell }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7026218\charrsid7026218 DOB:}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218
\cell {\*\bkmkstart Pbqb5C9J6tMikeJSVmis}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield
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Date of Birth}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\bkmkend Pbqb5C9J6tMikeJSVmis} }{\field\flddirty{\*\fldinst {
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}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid7799968 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7026218
\trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1384\clshdrawnil \cellx1276\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3365\clshdrawnil \cellx4641
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1077\clshdrawnil \cellx5718\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4772\clshdrawnil \cellx10490\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
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{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PLGj2nSz35l4uiYQfAlm}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 NHS Number}}}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 FORMTEXT
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\lang1024\langfe1024\noproof\insrsid7799968 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 \cell }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7026218\charrsid7026218 Gender:}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 \cell }{\field\fldedit{\*\fldinst {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 000200001400000014506e707078334c53356f5758583343676935316600000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Pnppx3LS5oWXX3Cgi51f}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 Gender(full)}}}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 FORMTEXT
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\lang1024\langfe1024\noproof\insrsid7799968 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7026218 \trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth10598\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid263663\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
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\cltxlrtb\clftsWidth3\clwWidth3365\clshdrawnil \cellx4641\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1077\clshdrawnil \cellx5718\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4772\clshdrawnil \cellx10490\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts22
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid12590267\charrsid7026218 Address:}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12590267\charrsid7026218 \cell }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12590267\charrsid7026218 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12590267\charrsid7026218 {\*\datafield
0002000014000000145062623177344546574b7257765277784772676d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Pbb1w4EFWKrWvRwxGrgm}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12590267\charrsid7026218
Home Full Address (single line)}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 }{\field\flddirty{\*\fldinst {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9}}}}}{\fldrslt {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid7799968 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12590267\charrsid7026218 \cell }{\rtlch\fcs1 \ab\af0\afs22 \ltrch\fcs0 \b\fs22\insrsid12590267\charrsid12590267 Emis no}{\rtlch\fcs1 \ab\af0\afs22 \ltrch\fcs0 \b\fs22\insrsid12590267 :}{\rtlch\fcs1
\ab\af0\afs22 \ltrch\fcs0 \b\fs22\insrsid12590267\charrsid12590267 \cell {\*\bkmkstart PKqD1cMrETXDRzTTuwdO}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12590267 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12590267 {\*\datafield 000200001400000014504b714431634d7245545844527a54547577644f00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PKqD1cMrETXDRzTTuwdO}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12590267 EMIS Number}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12590267 {\*\bkmkend PKqD1cMrETXDRzTTuwdO} }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\datafield
000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid7799968 \u8194\'20\u8194\'20\u8194\'20\u8194\'20
\u8194\'20}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12590267\charrsid7026218 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12590267
\trowd \irow2\irowband2\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10598\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid263663\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1384\clshdrawnil \cellx1276\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3365\clshdrawnil \cellx4641
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1077\clshdrawnil \cellx5718\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4772\clshdrawnil \cellx10490\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7026218 Telephone:}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7026218\charrsid7026218 \cell {\*\bkmkstart PM4tE9XYEflogtlhbRBQ}}
{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 {\*\datafield 000200001400000014504d34744539585945666c6f67746c686252425100000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PM4tE9XYEflogtlhbRBQ}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 Patient Mobile Telephone}}}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 {\*\bkmkend PM4tE9XYEflogtlhbRBQ} }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid7799968 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9}}}}}{\fldrslt {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid7799968 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 \cell }{\rtlch\fcs1 \ab\af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7026218\charrsid7026218 Email:\cell {\*\bkmkstart P77EG7kLLCgjj6hmmXaZ}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid7026218 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 {\*\datafield 0002000014000000145037374547376b4c4c43676a6a36686d6d58615a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname P77EG7kLLCgjj6hmmXaZ}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 Patient E-mail Address}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 {\*\bkmkend P77EG7kLLCgjj6hmmXaZ} }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968
{\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid7799968 \u8194\'20\u8194\'20\u8194
\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7026218
\trowd \irow3\irowband3\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10598\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid263663\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1384\clshdrawnil \cellx1276\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3365\clshdrawnil \cellx4641
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1077\clshdrawnil \cellx5718\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4772\clshdrawnil \cellx10490\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7026218\charrsid7026218 Language:}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 \cell }{\field\fldedit{\*\fldinst
{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 000200001400000014506c4f5259773767385a796173354b4f4872676f00000000000000000000000000
}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PlORYw7g8Zyas5KOHrgo}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 Main Language}}}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 FORMTEXT
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\lang1024\langfe1024\noproof\insrsid7799968 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 \cell }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7026218\charrsid7026218 Ethnicity:}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 \cell {\*\bkmkstart PElJLqrE7chxOQ21gtGR}}
{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield
00020000140000001450456c4a4c717245376368784f5132316774475200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PElJLqrE7chxOQ21gtGR}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218
Ethnic Origin}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\bkmkend PElJLqrE7chxOQ21gtGR} }{\field\flddirty{\*\fldinst {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 {\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9}}}}
}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid7799968 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7026218
\trowd \irow4\irowband4\lastrow \ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10598\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid263663\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1384\clshdrawnil \cellx1276\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3365\clshdrawnil \cellx4641
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1077\clshdrawnil \cellx5718\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4772\clshdrawnil \cellx10490\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4733039
\par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7026218 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid7026218
You have received this questionnaire because you have an upcoming appointment with your GP to talk about your ongoing symptoms of COVID-19.}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid4733039\charrsid7026218 Before the }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 appointment,}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid7026218
please complete this symptom questionnaire. It will help your GP plan your care more }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 effectively and}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid7026218
track your progress.}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid7026218
If you have difficulty with any of the questions please leave them blank and the clinician will review them with you }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid470930 d}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid7026218
uring your consultation.}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4733039 Thank you.
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4733039\charrsid7680525
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb40\keep\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid8074696 \rtlch\fcs1 \af0\afs26\alang1025 \ltrch\fcs0
\fs26\cf17\lang2057\langfe1033\loch\af31502\hich\af31502\dbch\af31501\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8074696\charrsid7680525 \hich\af31502\dbch\af31501\loch\f31502 COVID-19 overview
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid6495266\charrsid8925279 What date did your initial infection with COVID-19 start?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7680525\charrsid8925279 {\*\bkmkstart Text1} {\*\bkmkend Text1}}{\field{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \cs21\fs22\cf15\insrsid15035553 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\cf15\insrsid15035553 {\*\datafield 00000000000000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \cs21\fs22\cf15\lang1024\langfe1024\noproof\insrsid15035553 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \cs21\fs22\cf15\insrsid10898679\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid94235\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid6495266\charrsid8925279 Where did you receive care for COVID-19?
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\tx5245\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7026218 {\*\bkmkstart Check26}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid11870091 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid11870091 {\*\datafield
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid11870091 {\*\bkmkend Check26}\hich\af15\dbch\af15\loch\f15 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 I stayed at home}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7680525\charrsid8925279 {\*\bkmkstart Check2}{\*\bkmkstart Check3}\tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid8925279
\par {\*\bkmkstart Check27}{\*\bkmkend Check2}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid11870091 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid11870091 {\*\datafield 650000001400000007436865636b323700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check27}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid11870091 {\*\bkmkend Check27}\hich\af15\dbch\af15\loch\f15 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 I attended A&E department
\par {\*\bkmkstart Check28}{\*\bkmkend Check3}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11870091 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11870091 {\*\datafield
650000001400000007436865636b323800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check28}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11870091 {\*\bkmkend Check28} }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7799968 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 I was admitted to hospital
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid6495266\charrsid8925279 What were your COVID-19 test results?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \i\fs22\insrsid4733039\charrsid8925279 Please s}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \i\fs22\insrsid6495266\charrsid8925279 elect multiple options if needed
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\tx5245\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7026218 {\*\bkmkstart Check4}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield
650000001400000006436865636b3400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 {\*\bkmkend Check4} }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid6495266\charrsid8925279 I had a positive swab test}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\bkmkstart Check5}\tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid8925279
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check5}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 {\*\bkmkend Check5} }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid6495266\charrsid8925279 I had a positive antibody test
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\*\bkmkstart Check6}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield
650000001400000006436865636b3600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check6}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery284\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 {\*\bkmkend Check6} }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid6495266\charrsid8925279 I was not tested for COVID-19
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4733039\charrsid7680525
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb40\keep\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid8074696 \rtlch\fcs1 \af0\afs26\alang1025 \ltrch\fcs0
\fs26\cf17\lang2057\langfe1033\loch\af31502\hich\af31502\dbch\af31501\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8074696\charrsid7680525 \hich\af31502\dbch\af31501\loch\f31502 Your COVID-19 symptoms
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6495266 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \b\fs22\insrsid6495266\charrsid8925279 What symptoms did you have in the first two weeks of COVID-19 infection?
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \i\fs22\insrsid410723\charrsid8925279 Please tick as many as apply
\par \sect }\sectd \ltrsect\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj \pard\plain \ltrpar
\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6495266 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart Check7}
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 {\*\bkmkend Check7} }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 None
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Fever
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Cough
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Breathlessness
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Fatigue
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Chest pain
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Chest tightness
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Palpitations
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Dizziness
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Vertigo
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Muscle aches
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Joint pain
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Headache
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Loss of smell or taste
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Sore throat
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Pain in abdomen
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Diarrhoea
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Constipation
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Vomiting / nausea
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Seizures
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Leg or arm weakness / tingling
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Poor sleep
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Brain fog or problems with memory / concentrating
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margrsxn985\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx292\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7026218\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Changes in menstrual cycle in women
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid410723\charrsid8925279 \sect }\sectd \ltrsect\marglsxn1440\margrsxn1440\margtsxn709\margbsxn993\sbknone\linex0\headery708\footery352\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6495266 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid163199\charrsid8925279
\par }\pard \ltrpar\ql \li-709\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin-709\itap0\pararsid6502916 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6495266\charrsid8925279 Other}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid410723\charrsid8925279 symptoms}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid6502916 (please state)
\par {\*\bkmkstart Text8}}{\field{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\cf15\insrsid15035553 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\cf15\insrsid15035553 {\*\datafield 000000000000000005546578743800000000000000000000000000
}{\*\formfield{\fftype0\fftypetxt0{\*\ffname Text8}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\cf15\lang1024\langfe1024\noproof\insrsid15035553 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn709\margbsxn993\sbknone\linex0\headery708\footery352\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7680525\charrsid8925279 {\*\bkmkend Text8}
\page }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7680525\charrsid6502916
\par }\pard \ltrpar\ql \li-851\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin-851\itap0\pararsid7026218 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid4733039\charrsid8925279 What symptoms have you experienced in the last two weeks?}
{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\cf15\insrsid4733039\charrsid8925279
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \i\fs22\insrsid8074696\charrsid8925279 Please tick as many as apply}{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \i\fs22\insrsid4733039\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \i\fs22\insrsid8074696\charrsid8925279 \sect }\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj \pard\plain \ltrpar
\ql \li-851\ri45\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin45\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279
{\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid7026218\charrsid8925279 \hich\af15\dbch\af15\loch\f15 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Fever
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Cough
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Breathlessness
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Fatigue
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Chest pain
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Chest tightness
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Palpitations
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Dizziness
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Vertigo
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Muscle aches
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Joint pain
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Headache
\par }\pard \ltrpar\ql \li-284\ri45\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin45\lin-284\itap0\pararsid7026218 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield
650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Loss of smell or taste
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Sore throat
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Pain in abdomen
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Diarrhoea
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Constipation
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Vomiting / nausea
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Seizures
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Leg or arm weakness / tingling
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Poor sleep
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Brain fog or problems with memory / concentrating
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\margtsxn1440\margbsxn1440\sbknone\linex0\headery708\footery708\cols2\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid410723\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid94235\charrsid8925279 }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4733039\charrsid8925279 Changes in menstrual cycle in women
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4733039\charrsid7680525 \sect }\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj \pard\plain \ltrpar
\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid4733039\charrsid7680525
\par Other symptoms (please state)
\par {\*\bkmkstart Text3}}{\field{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \cs21\cf15\insrsid15035553 FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \cs21\cf15\insrsid15035553 {\*\datafield 000000000000000005546578743300000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0{\*\ffname Text3}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \cs21\cf15\lang1024\langfe1024\noproof\insrsid15035553 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \cs21\cf15\insrsid4733039\charrsid7680525 {\*\bkmkend Text3}
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7680525\charrsid7680525
\par }\pard\plain \ltrpar\s2\ql \li-851\ri-761\sb40\keep\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs26\alang1025 \ltrch\fcs0
\fs26\cf17\lang2057\langfe1033\loch\af31502\hich\af31502\dbch\af31501\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8074696\charrsid7680525 \hich\af31502\dbch\af31501\loch\f31502 Your overall wellbeing
\par }\pard\plain \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \b\fs22\lang1024\langfe1024\noproof\langfenp2057\insrsid16215848\charrsid8925279 Do you still feel unwell?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\lang1024\langfe1024\noproof\langfenp2057\insrsid7026218\charrsid8925279 \tab
\tab \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\lang1024\langfe1024\noproof\langfenp2057\insrsid7680525\charrsid8925279 \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield
650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\langfenp2057\insrsid8074696\charrsid8925279 }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\langfenp2057\insrsid16215848\charrsid8925279 Yes}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\langfenp2057\insrsid7026218\charrsid8925279 \tab \tab }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 \hich\af15\dbch\af15\loch\f15 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\loch\af15\hich\af15\dbch\af15\insrsid94235\charrsid8925279 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\langfenp2057\insrsid8074696\charrsid8925279 }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\langfenp2057\insrsid16215848\charrsid8925279 No}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16215848\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12124732\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid16215848\charrsid8925279 What percentage of your usual health (before COVID-19) do you feel?
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \i\fs22\insrsid8074696\charrsid8925279 Please choose a number between 0-100%}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \i\fs22\insrsid7026218\charrsid8925279 {\*\bkmkstart Text4}\tab {\*\bkmkend Text4}}{\field{\*\fldinst {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15035553 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15035553 {\*\datafield 00000000000000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0}}}}{\fldrslt {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid15035553 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279
\par
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid16215848\charrsid8925279 Are you well enough to work?
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\datafield
650000001400000006436865636b3800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check8}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid4983813\charrsid8925279 Yes, full Time}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\bkmkstart Check8} {\*\bkmkend Check8}\tab \tab \tab \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid8925279 \tab
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid4983813\charrsid8925279 Yes, }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 P}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4983813\charrsid8925279 art time }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid8925279
\par {\*\bkmkstart Check10}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\datafield
650000001400000007436865636b313000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check10}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\bkmkend Check10} }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4983813\charrsid8925279 I am not well enough to work}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\bkmkstart Check11}\tab \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid8925279 \tab
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\datafield
650000001400000007436865636b313100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check11}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\bkmkend Check11} }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4983813\charrsid8925279 I am retired }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279
\par {\*\bkmkstart Check12}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\datafield
650000001400000007436865636b313200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check12}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\bkmkend Check12} }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid4983813\charrsid8925279 I am unemployed at present }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4983813\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid16215848\charrsid8925279 Do you feel your symptoms are improving?
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid4983813\charrsid8925279 Week by week}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid7026218\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4983813\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid8925279 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12872800
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid4983813\charrsid8925279 Month by month}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid4983813\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid8925279 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12872800
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\datafield
010000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid4983813\charrsid8925279 Up and Down }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 \tab \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12872800
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 {\*\datafield
010000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid4983813\charrsid8925279 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid8074696\charrsid8925279
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs26 \ltrch\fcs0 \b\fs26\cf17\loch\af31502\hich\af31502\dbch\af31501\insrsid11427736
\par }\pard\plain \ltrpar\s2\ql \li-851\ri-761\sb40\keep\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin-761\lin-851\itap0\pararsid12872800 \rtlch\fcs1 \af0\afs26\alang1025 \ltrch\fcs0
\fs26\cf17\lang2057\langfe1033\loch\af31502\hich\af31502\dbch\af31501\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8074696\charrsid7680525 \hich\af31502\dbch\af31501\loch\f31502 Your mental health}{\rtlch\fcs1 \af0 \ltrch\fcs0
\b\insrsid12872800\charrsid12872800
\par }\pard\plain \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid9332061 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid16215848\charrsid9332061 Many patients have felt anxious or low as a result of their illness and due to the stress caused by the }{\rtlch\fcs1 \af39\afs22 \ltrch\fcs0 \fs22\insrsid16215848\charrsid9332061
pandemic. Please }{\rtlch\fcs1 \af39\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid9332061 complete }{\rtlch\fcs1 \ab\af39\afs22 \ltrch\fcs0 \b\fs22\cf18\insrsid11427736\charrsid9332061 both}{\rtlch\fcs1 \af39\afs22 \ltrch\fcs0
\fs22\cf18\insrsid11427736\charrsid9332061 }{\rtlch\fcs1 \af39\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid9332061 the questionnaires below }{\rtlch\fcs1 \af39\afs22 \ltrch\fcs0 \fs22\insrsid16215848\charrsid9332061
\par }\pard \ltrpar\ql \li-851\ri0\widctlpar\wrapdefault\faauto\rin0\lin-851\itap0\pararsid11427736 {\rtlch\fcs1 \af39\afs22 \ltrch\fcs0 \fs22\cf19\insrsid11427736
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid11427736 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\cf18\insrsid11427736\charrsid11427736 Patient Health Questionnaire (PHQ-9)}{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \b\fs22\cf18\insrsid11427736 \line }{\rtlch\fcs1 \ab\af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 Over the }{\rtlch\fcs1 \ab\ai\af0\afs22 \ltrch\fcs0 \i\fs22\ul\insrsid11427736\charrsid11427736 last}{\rtlch\fcs1
\ab\af0\afs22 \ltrch\fcs0 \fs22\ul\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \ab\ai\af0\afs22 \ltrch\fcs0 \i\fs22\ul\insrsid11427736\charrsid11427736 two weeks}{\rtlch\fcs1 \ab\af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736
, how often have you been bothered by any of the following problems?
\par }\pard \ltrpar\qj \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid11427736 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2660\clcbpatraw20 \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1418\clcbpatraw20 \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1729\clcbpatraw20 \cellx4848\clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2818\clcbpatraw20 \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2115\clcbpatraw20 \cellx9781\pard\plain \ltrpar\qj \li0\ri-110\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-110\lin0\pararsid14631387\yts22 \rtlch\fcs1 \af0\afs24\alang1025
\ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736 Score\cell }\pard \ltrpar
\qc \li0\ri-110\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-110\lin0\pararsid14631387\yts22 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736 0\cell 1\cell 2\cell 3\cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2660\clcbpatraw20 \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1418\clcbpatraw20 \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1729\clcbpatraw20 \cellx4848\clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2818\clcbpatraw20 \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2115\clcbpatraw20 \cellx9781\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14631387\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Little interest or pleasure in doing things?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid11427736\charrsid10815137 \cell }\pard \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14623962\yts22 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 \cell }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid11427736\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Feeling down, depressed, or hopeless?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid10815137
\cell }\pard \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14623962\yts22 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1
\af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736 \trowd \irow2\irowband2\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10
\trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\row \ltrrow}\trowd \irow3\irowband3\ltrrow\ts22\trgaph108\trrh810\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10
\trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid11427736\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Trouble falling or staying asleep, or sleeping too much?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid11427736\charrsid10815137 \cell }\pard \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14623962\yts22 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow3\irowband3\ltrrow\ts22\trgaph108\trrh810\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\row \ltrrow}\trowd \irow4\irowband4\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10
\trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid11427736\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Feeling tired or having little energy?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid11427736\charrsid10815137 \cell }\pard \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14623962\yts22 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow4\irowband4\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid11427736\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Poor appetite or overeating?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid10815137 \cell
}\pard \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14623962\yts22 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow5\irowband5\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\row \ltrrow}\trowd \irow6\irowband6\ltrrow\ts22\trgaph108\trrh1017\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10
\trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid11427736\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Feeling bad about yourself - or that you are a failure or have let yourself or your family down?}{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid10815137 \cell }\pard \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14623962\yts22 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow6\irowband6\ltrrow\ts22\trgaph108\trrh1017\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\row \ltrrow}\trowd \irow7\irowband7\ltrrow\ts22\trgaph108\trrh989\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10
\trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid11427736\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Trouble concentrating on things, such as reading the newspaper or watching television?}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \b\fs22\insrsid11427736\charrsid10815137 \cell }\pard \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14623962\yts22 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow7\irowband7\ltrrow\ts22\trgaph108\trrh989\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\row \ltrrow}\trowd \irow8\irowband8\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10
\trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid11427736\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Moving}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736 /}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid11427736\charrsid11427736 speaking so slowly }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736 or being }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 fidgety}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid11427736 /}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 restless?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid10815137 \cell }\pard \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14623962\yts22 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow8\irowband8\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid11427736\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Thoughts that you would be better off dead, or of hurting yourself in some way?}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \b\fs22\insrsid11427736\charrsid10815137 \cell }\pard \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14623962\yts22 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow9\irowband9\lastrow \ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1729\clshdrawnil \cellx4848\clvertalt\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2818\clshdrawnil \cellx7666\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2115\clshdrawnil \cellx9781\row }\pard \ltrpar\qj \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid11427736 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid11427736 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\cf6\insrsid11427736\charrsid10815137 * }{\rtlch\fcs1 \af0 \ltrch\fcs0
\b\insrsid11427736\charrsid11427736 PHQ9}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\cf6\insrsid11427736 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid11427736 Please total up the score:\tab \tab }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 {\*\datafield 00080000000000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt1}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\lang1024\langfe1024\noproof\insrsid11427736 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid11427736 /27}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid11427736\charrsid7680525
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\par }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\cf18\insrsid11427736\charrsid11427736 Generalised Anxiety Disorder Questionnaire (GAD-7)
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid11427736 {\rtlch\fcs1 \ab\af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 Over the }{\rtlch\fcs1 \ab\ai\af0\afs22
\ltrch\fcs0 \i\fs22\ul\insrsid11427736\charrsid11427736 last}{\rtlch\fcs1 \ab\af0\afs22 \ltrch\fcs0 \fs22\ul\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \ab\ai\af0\afs22 \ltrch\fcs0 \i\fs22\ul\insrsid11427736\charrsid11427736 two weeks}{\rtlch\fcs1
\ab\af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 , how often have you been bothered by any of the following problems?
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2660\clcbpatraw20 \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1418\clcbpatraw20 \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1727\clcbpatraw20 \cellx4846\clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2819\clcbpatraw20 \cellx7665\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2116\clcbpatraw20 \cellx9781\pard\plain \ltrpar\qj \li0\ri-110\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-110\lin0\pararsid14631387\yts22 \rtlch\fcs1 \af0\afs24\alang1025
\ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736 Score\cell }\pard \ltrpar
\qc \li0\ri-110\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-110\lin0\pararsid14631387\yts22 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736 0\cell 1\cell 2\cell 3\cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2660\clcbpatraw20 \cellx1701\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1418\clcbpatraw20 \cellx3119\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1727\clcbpatraw20 \cellx4846\clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2819\clcbpatraw20 \cellx7665\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2116\clcbpatraw20 \cellx9781\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1727\clshdrawnil \cellx4846\clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2819\clshdrawnil \cellx7665\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2116\clshdrawnil \cellx9781\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14631387\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Feeling nervous, anxious}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736 , }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 on edge?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 \cell }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1727\clshdrawnil \cellx4846\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2819\clshdrawnil \cellx7665\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2116\clshdrawnil \cellx9781\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14631387\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Not being able to stop or control worrying?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow2\irowband2\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1727\clshdrawnil \cellx4846\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2819\clshdrawnil \cellx7665\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2116\clshdrawnil \cellx9781\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14631387\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Worrying too much about different things?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow3\irowband3\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1727\clshdrawnil \cellx4846\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2819\clshdrawnil \cellx7665\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2116\clshdrawnil \cellx9781\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14631387\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Trouble relaxing?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid14623962\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid11427736\charrsid11427736 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow4\irowband4\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1727\clshdrawnil \cellx4846\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2819\clshdrawnil \cellx7665\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2116\clshdrawnil \cellx9781\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14631387\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Being so restless that it is hard to sit still?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow5\irowband5\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1727\clshdrawnil \cellx4846\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2819\clshdrawnil \cellx7665\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2116\clshdrawnil \cellx9781\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14631387\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Becoming easily annoyed or irritable?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid10815137
\cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow6\irowband6\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1727\clshdrawnil \cellx4846\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2819\clshdrawnil \cellx7665\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2116\clshdrawnil \cellx9781\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid14631387\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid11427736\charrsid11427736 Feeling afraid as if something awful might happen?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid11427736 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid11427736\charrsid11427736 Not at all}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736 Several days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid14623962 More than half}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 the days}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 Nearly every day}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736\charrsid10815137 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\trowd \irow7\irowband7\lastrow \ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10740\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14623962\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx1701\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1418\clshdrawnil \cellx3119\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1727\clshdrawnil \cellx4846\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2819\clshdrawnil \cellx7665\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2116\clshdrawnil \cellx9781\row }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11427736
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid11427736 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\cf6\insrsid11427736\charrsid10815137 * }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid11427736
GAD7 Please total up the score:\tab \tab }{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid11427736 {\*\datafield 00080000000000000000000000000000000000000000
}{\*\formfield{\fftype0\fftypetxt1}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid11427736 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid11427736 /21}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid11427736\charrsid7680525
\par }\pard\plain \ltrpar\s2\ql \li-851\ri-761\sb40\keep\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin-761\lin-851\itap0\pararsid7680525 \rtlch\fcs1 \af0\afs26\alang1025 \ltrch\fcs0
\fs26\cf17\lang2057\langfe1033\loch\af31502\hich\af31502\dbch\af31501\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid14623962
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8074696\charrsid7680525 \hich\af31502\dbch\af31501\loch\f31502 Fatigue}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid10815137 \hich\af31502\dbch\af31501\loch\f31502 (using Fatigue assessment scale tool)}{\rtlch\fcs1
\af0 \ltrch\fcs0 \b\insrsid8074696\charrsid7680525
\par }\pard\plain \ltrpar\qj \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid410723\charrsid9332061 The following statements refer to how you usually feel. Per statement you can choose out of one of five answer categories, varying from Never to Alway
s. Please give an answer to each question, even if you have no complaints at the moment.}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12124732\charrsid9332061
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137
\par }\pard \ltrpar\ql \li-851\ri0\widctlpar\wrapdefault\faauto\rin0\lin-851\itap0\pararsid10815137 {\rtlch\fcs1 \af41\afs18 \ltrch\fcs0 \f41\fs18\cf19\insrsid10815137 1 - Never}{\rtlch\fcs1 \af41\afs18 \ltrch\fcs0 \f41\fs18\cf21\insrsid10815137
\par }{\rtlch\fcs1 \af41\afs18 \ltrch\fcs0 \f41\fs18\cf22\insrsid10815137 2 - Sometimes (about monthly or less)}{\rtlch\fcs1 \af41\afs18 \ltrch\fcs0 \f41\fs18\cf21\insrsid10815137
\par }{\rtlch\fcs1 \af41\afs18 \ltrch\fcs0 \f41\fs18\cf23\insrsid10815137 3 - Regularly (about a few times a month)}{\rtlch\fcs1 \af41\afs18 \ltrch\fcs0 \f41\fs18\cf21\insrsid10815137
\par }{\rtlch\fcs1 \af41\afs18 \ltrch\fcs0 \f41\fs18\cf24\insrsid10815137 4 - Often (about weekly)}{\rtlch\fcs1 \af41\afs18 \ltrch\fcs0 \f41\fs18\cf21\insrsid10815137
\par }\pard \ltrpar\qj \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid10815137 {\rtlch\fcs1 \af41\afs18 \ltrch\fcs0 \f41\fs18\cf25\insrsid10815137 5 - Always (about every day)}{\rtlch\fcs1 \af0
\ltrch\fcs0 \insrsid10815137
\par }\pard \ltrpar\qj \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7680525
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3227\clcbpatraw20 \cellx2268\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1314\clcbpatraw20 \cellx3582\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1691\clcbpatraw20 \cellx5273\clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1410\clcbpatraw20 \cellx6683\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1692\clcbpatraw20 \cellx8375\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1307\clcbpatraw20 \cellx9682
\pard\plain \ltrpar\qj \li0\ri-110\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-110\lin0\pararsid10815137\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af0 \ltrch\fcs0 \insrsid10815137 Score\cell }\pard \ltrpar\qc \li0\ri-110\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-110\lin0\pararsid10815137\yts22 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137 1\cell 2\cell 3\cell 4\cell 5
\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid10815137 \trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3227\clcbpatraw20 \cellx2268\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1314\clcbpatraw20 \cellx3582\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1691\clcbpatraw20 \cellx5273\clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1410\clcbpatraw20 \cellx6683\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1692\clcbpatraw20 \cellx8375\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1307\clcbpatraw20 \cellx9682
\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\pard\plain \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid10815137\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid10815137\charrsid10815137 I am bothered by fatigue\cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid10815137\charrsid8925279 Never}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Sometimes}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Regularly}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Often}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Always}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137 \trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid10815137\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid10815137\charrsid10815137 I get tired very quickly\cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid10815137\charrsid8925279 Never}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Sometimes}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Regularly}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Often}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Always}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137 \trowd \irow2\irowband2\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid10815137\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid10815137\charrsid10815137 I don\rquote t do much during the day\cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid10815137\charrsid8925279 Never}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Sometimes}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Regularly}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Often}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Always}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137 \trowd \irow3\irowband3\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid10815137\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid10815137\charrsid10815137 I have enough energy for everyday life\cell }\pard \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid16271943\yts22 {\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid16271943\charrsid16271943 Always}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 \cell }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid16271943 Often}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 \cell }\pard \ltrpar\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid10815137\yts22
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 Regularly\cell }\pard \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid16271943\yts22 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 FORMCHECKBOX }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid16271943 Sometimes}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 FORMCHECKBOX }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid16271943 Never}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid16271943 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025
\ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137 \trowd \irow4\irowband4\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid10815137\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid10815137\charrsid10815137 Physically I feel exhausted\cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid10815137\charrsid8925279 Never}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Sometimes}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Regularly}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Often}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Always}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137 \trowd \irow5\irowband5\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid10815137\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid10815137\charrsid10815137 I have problems to start things\cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid10815137\charrsid8925279 Never}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Sometimes}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Regularly}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Often}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Always}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137 \trowd \irow6\irowband6\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid10815137\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid10815137\charrsid10815137 I have problems to think clearly\cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid10815137\charrsid8925279 Never}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Sometimes}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Regularly}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Often}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Always}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137 \trowd \irow7\irowband7\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid10815137\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid10815137\charrsid10815137 I feel no desire to do anything\cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid10815137\charrsid8925279 Never}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Sometimes}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Regularly}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Often}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Always}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137 \trowd \irow8\irowband8\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid10815137\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid10815137\charrsid10815137 Mentally, I feel exhausted\cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid10815137\charrsid8925279 Never}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX
}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Sometimes}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Regularly}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid8925279 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Often}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279
{\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137\charrsid8925279 Always}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid10815137\charrsid10815137 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137 \trowd \irow9\irowband9\ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri32\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin32\lin0\pararsid16271943\yts22 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid16271943\charrsid10815137 When I am doing something, I can concentrate quite well\cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid16271943\charrsid16271943 Always}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid16271943 Often}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 FORMCHECKBOX }{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 Regularly\cell }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 {\*\datafield
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid16271943 Sometimes}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 FORMCHECKBOX }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid16271943 Never}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid16271943\charrsid16271943 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025
\ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid16271943 \trowd \irow10\irowband10\lastrow \ltrrow\ts22\trgaph108\trrh537\trleft-959\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth3\trwWidth10641\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16271943\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind-851\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3227\clshdrawnil \cellx2268\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1314\clshdrawnil \cellx3582\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1691\clshdrawnil \cellx5273\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1410\clshdrawnil \cellx6683\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1692\clshdrawnil \cellx8375\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1307\clshdrawnil \cellx9682\row }\pard \ltrpar
\qj \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10815137
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7680525 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\cf6\insrsid10815137\charrsid10815137 * }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid10815137
Please total up the score:\tab \tab }{\field{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid10815137 {\*\datafield 00080000000000000000000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt1}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid10815137 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid10815137 /50}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8925279\charrsid7680525
\par }\pard\plain \ltrpar\s2\ql \li-851\ri-761\sb40\keep\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs26\alang1025 \ltrch\fcs0
\fs26\cf17\lang2057\langfe1033\loch\af31502\hich\af31502\dbch\af31501\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid10815137
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8074696\charrsid7680525 \hich\af31502\dbch\af31501\loch\f31502 Breathlessness}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8074696
\par }\pard\plain \ltrpar\qj \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af0 \ltrch\fcs0 \insrsid410723\charrsid7680525 P}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid16215848\charrsid7680525 lease rate your experience of breathlessness using the scales below. The first is before you had COVID-19, the second is how you feel now:
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid16215848\charrsid7680525
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid16215848\charrsid8925279 Which of the following best describes your experience of breathlessness }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid12521887 BEFORE}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid16215848\charrsid8925279 you had COVID-19?
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\tx-426\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid12521887 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 {\*\datafield 650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check18}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887 \tab }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 I only get short of breath on strenuous exercise
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 {\*\datafield
650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check18}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12521887 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 I get short of breath when hurrying or walking up a slight hill
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 {\*\datafield
650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check18}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12521887 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 I get short of breath when walking at my own pace
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 {\*\datafield
650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check18}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12521887 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 I have to stop for a breath after a few minutes of walking on level ground
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 {\*\datafield
650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check18}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12521887 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 I am too breathless to leave the house, or I get short of breath when getting dressed
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid16215848\charrsid8925279 Which of the following best describes your experience of breathlessness }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid12521887 AFTER }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid16215848\charrsid8925279 you had COVID-19?
\par }\pard \ltrpar\ql \li-851\ri-761\widctlpar\tx-426\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid12521887 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 {\*\datafield 650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check18}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887 \tab }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 I only get short of breath on strenuous exercise
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 {\*\datafield
650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check18}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12521887 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 I get short of breath when hurrying or walking up a slight hill
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 {\*\datafield
650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check18}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12521887 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 I get short of breath when walking at my own pace
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 {\*\datafield
650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check18}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12521887 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 I have to stop for a breath after a few minutes of walking on level ground
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid12521887\charrsid8925279 {\*\datafield
650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check18}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid12521887 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887\charrsid12521887 I am too breathless to leave the house, or I get short of breath when getting dressed
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7680525\charrsid8925279 \page }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\cf17\loch\af31502\hich\af31502\dbch\af31501\insrsid7680525\charrsid8925279
\par }\pard\plain \ltrpar\s2\ql \li-851\ri-761\sb40\keep\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs26\alang1025 \ltrch\fcs0
\fs26\cf17\lang2057\langfe1033\loch\af31502\hich\af31502\dbch\af31501\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid15083790\charrsid7680525 \hich\af31502\dbch\af31501\loch\f31502 Your q}{\rtlch\fcs1 \af0 \ltrch\fcs0
\b\insrsid163199\charrsid7680525 \hich\af31502\dbch\af31501\loch\f31502 uality of life}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid163199
\par }\pard\plain \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af0 \ltrch\fcs0 \insrsid16215848\charrsid4733039 Please answer the following}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15083790 questions about you feel today.}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1715961\charrsid4733039
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid16215848\charrsid4733039
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid16215848\charrsid7026218 Mobility
\par {\*\bkmkstart Check19}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\bkmkend Check19} }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 I have no problems in walking about}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab \tab \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 I have severe problems in walking about
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have slight problems in walking about}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 I am unable to walkabout
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have moderate problems in walking about}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab \tab
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid16215848\charrsid7026218 Self-care
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have no problems washing or dressing myself}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 I have severe problems washing}
{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 /}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 dressing myself
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have slight problems washing or dressing myself}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 I am unable to wash or dress myself.
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have moderate problems washing}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 /}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 dressing myself}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid9245882\charrsid7026218
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid410723\charrsid7026218 Usual activities
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have no problems doing my usual activities}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 I have severe problems doing my usual activities
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have slight problems doing my usual activities}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 I am unable to do my usual activities
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have moderate problems doing my usual activities
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15083790\charrsid7026218
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid410723\charrsid7026218 Pain / Discomfort
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have no pain or discomfort}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab \tab \tab \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 I have severe pai
n or discomfort
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have slight pain or discomfort}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab \tab \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218
I have extreme pain or discomfort
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I have moderate pain or discomfort
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid410723\charrsid7026218
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid410723\charrsid7026218 Anxiety / depression
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I am not anxious or depressed}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab \tab \tab \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218
FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 I }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \fs22\insrsid12521887 am}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 severe}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887 ly}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218
anxious or depressed
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887 am}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 slight}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887 ly}{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 anxious or depressed}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218 \tab \tab \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid7026218\charrsid7026218 I }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887 am }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 extremely anxious or depressed
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7026218\charrsid7026218 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\fs22\insrsid9245882\charrsid7026218 I }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887 am}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 moderate}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12521887 ly}{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid7026218 anxious or depressed
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid410723\charrsid7026218
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid410723\charrsid7026218 On a scale of 1 to 100 (where 1 is the worst health you can imagine and 100 is the best health you can imagine) \endash we would like }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid15083790\charrsid7026218 you}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid410723\charrsid7026218 know how good }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid15083790\charrsid7026218 to}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid410723\charrsid7026218 bad your health is }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\i\fs22\insrsid410723\charrsid7026218 today}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid410723\charrsid7026218 .}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\b\fs22\insrsid12124732\charrsid7026218
\par {\*\bkmkstart Text5}}{\field{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15035553 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15035553 {\*\datafield 000000000000000005546578743500000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0{\*\ffname Text5}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\lang1024\langfe1024\noproof\insrsid15035553 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid12124732\charrsid7026218 {\*\bkmkend Text5}
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15083790
\par }\pard\plain \ltrpar\s2\ql \li-851\ri-761\sb40\keep\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs26\alang1025 \ltrch\fcs0
\fs26\cf17\lang2057\langfe1033\loch\af31502\hich\af31502\dbch\af31501\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid163199 \hich\af31502\dbch\af31501\loch\f31502 Being active}{\rtlch\fcs1 \af0 \ltrch\fcs0
\b\insrsid163199\charrsid163199
\par }\pard\plain \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af0 \ltrch\fcs0 \insrsid16215848\charrsid4733039 Please answer these questions about }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15083790 how you feel after being active.}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1715961\charrsid4733039
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid16215848\charrsid4733039
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid16215848\charrsid8925279 Do you feel worse after being active?}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid7026218\charrsid8925279 \tab {\*\bkmkstart Check20}\tab }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \b\fs22\insrsid2907639 \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid9245882\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid9245882\charrsid8925279
{\*\datafield 650000001400000007436865636b323000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check20}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid7026218\charrsid8925279 {\*\bkmkend Check20} }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid9245882\charrsid8925279 Yes {\*\bkmkstart Check21}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid9245882\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \cs21\fs22\insrsid9245882\charrsid8925279 {\*\datafield 650000001400000007436865636b323100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check21}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid7026218\charrsid8925279 {\*\bkmkend Check21} }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid9245882\charrsid8925279 No}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\cf15\insrsid9245882\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\cf15\insrsid16215848\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15358747\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid9245882\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid16215848\charrsid8925279 If you answer yes to the previous question, how long do you feel worse after activity?
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid2907639 {\*\bkmkstart Check22}
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid7026218\charrsid8925279 {\*\datafield
650000001400000007436865636b323200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check22}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid14623962 {\*\bkmkend Check22} Less than }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \cs21\fs22\insrsid9245882\charrsid8925279 1 hour}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid7026218\charrsid8925279 \tab }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \cs21\fs22\insrsid2907639 \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid7026218\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid7026218\charrsid8925279
{\*\datafield 650000001400000007436865636b323200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check22}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid7026218\charrsid8925279 }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid15358747\charrsid8925279 2-3 hours}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid14623962 {\*\bkmkstart Check23} \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid2907639 \tab }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 {\*\datafield 650000001400000007436865636b323300000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check23}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 {\*\bkmkend Check23} 4-12 hours}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid7026218\charrsid8925279 {\*\bkmkstart Check24} \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\cs21\fs22\insrsid14623962 \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid2907639 \tab }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 {\*\bkmkend Check24} 13-24 hours}{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid14623962 {\*\bkmkstart Check25} \tab }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid2907639
\par }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 FORMCHECKBOX }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 {\*\datafield
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 {\*\bkmkend Check25} }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid14623962 More than }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15358747\charrsid8925279 24 hours}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15083790\charrsid8925279
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15358747
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7026218\charrsid9245882
\par }\pard\plain \ltrpar\s2\ql \li-851\ri-761\sb40\keep\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs26\alang1025 \ltrch\fcs0
\fs26\cf17\lang2057\langfe1033\loch\af31502\hich\af31502\dbch\af31501\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid15083790\charrsid15083790 \hich\af31502\dbch\af31501\loch\f31502 What matters to you?
\par }\pard\plain \ltrpar\ql \li-851\ri-761\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin-761\lin-851\itap0\pararsid7026218 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \f31506\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \b\fs22\insrsid15083790\charrsid8925279 Overall, what is most important to you in terms of your COVID-19 recovery?
\par {\*\bkmkstart Text6}}{\field{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15035553 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15035553 {\*\datafield 000000000000000005546578743600000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0{\*\ffname Text6}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\lang1024\langfe1024\noproof\insrsid15035553 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15083790\charrsid8925279 {\*\bkmkend Text6}
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15358747\charrsid8925279
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\fs22\insrsid15083790\charrsid8925279 Is there anything else you would like to share with your GP about your COVID-19 recovery before your consultation?
\par {\*\bkmkstart Text7}}{\field{\*\fldinst {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15035553 FORMTEXT }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\insrsid15035553 {\*\datafield 000000000000000005546578743700000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \cs21\fs22\lang1024\langfe1024\noproof\insrsid15035553 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\marglsxn1440\margrsxn1440\sbknone\linex0\headery284\footery388\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7680525\sftnbj {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid15083790\charrsid8925279 {\*\bkmkend Text7}
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15083790
\par Thank you for completing this questionnaire.}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15083790\charrsid15083790
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