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ICANWORK

RR#2,
St. Albert, Alberta
T8N 1M9

John Gibson (780) 554-5254


Shelley Buckley (Lynem) (780) 554-5154
Fax: (780) 486-3477

PERCEIVED HEALTH STATUS QUESTIONNAIRE

Compared to other persons of your age, how would you rate your overall
health?

5. Excellent (never prevents activities)

4. Good (rarely prevents activities)

3. Fair (occasionally prevents activities)

2. Poor (very often prevents activities)

1. Very Poor ( health troubles or infirmity all the time prevents most
activities-requires confinement to bed)