Instructions: For each question, choose the option that best matches your current health and experiences.
1. How do you rate your energy levels most days?
a) High—I rarely feel tired or fatigued
b) Average—a little tired but manageable
c) Low—fatigue is common, with some days worse than others
d) Very low—most days are a struggle due to tiredness
2. How much do physical aches, pains, or stiffness limit your daily activities?
a) Not at all
b) Occasionally, but I work around it
c) Frequently, I need to modify my activities
d) Almost always, I avoid or cannot do many things
3. How is your memory compared to a few years ago?
a) Just as good, or even better
b) Occasionally forgetful, nothing major
c) Increasingly forgetful or “foggy”
d) It worries me; family/friends have noticed
4. How often do you think about or manage health concerns (medication, appointments, symptoms, etc.)?
a) Rarely
b) Sometimes, but it doesn’t interfere with life
c) Regularly—it’s a significant part of my routine
d) Constantly; health issues dominate my day
5. How would you describe your mobility (walking, getting upstairs, hiking, getting in and out of the car, etc.)?
a) Fully mobile, no issues
b) Some minor difficulties, but manageable
c) Need help or take precautions
d) Significant limitations; need aids or assistance
6. How often do you feel “old” because of your health?
a) Never
b) Sometimes
c) Often
d) Almost all the time
7. How do you react to physical setbacks (illness, injury)?
a) Recover quickly, little impact
b) Need more time, but return to normal
c) Recovery is slow and challenging
d) Setbacks feel devastating or permanent
Scoring:
Each “a” = 1 point
Each “b” = 2 points
Each “c” = 3 points
Each “d” = 4 points
Add up your points:
7–11 points: Your health makes you feel young or your actual age
12–18 points: Your health makes you feel somewhat older
19–23 points: Your health makes you feel noticeably older
24–28 points: Your health contributes to feeling much older than your age
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