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2. 
4. Case Number:
   Your case number can be found on your EBT card. (Example: 1B12345)
5. Date:
   Date:

   Date:
7. Instructions:
   Please indicate the quality of your health and life at present, from “poor” to “excellent,” by selecting any of the ten points on the line for each of the following Items:
9. 1. Physical Well-being (feeling energetic, free of pain and physical problems)

   1. 1- Poor
   2. 2
   3. 3
   4. 4
   5. 5
   6. 6
   7. 7
   8. 8
   9. 9
   10. 10-Excellent
11. 2. Mental/Emotional Well-Being (feeling good, comfortable with yourself, clear headed)

    1. 1-Poor
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8
    9. 9
    10. 10-Excellent
13. 3. Self-Care and Independent Functioning (carrying out daily living tasks; making own decisions)

    1. 1-Poor
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8
    9. 9
    10. 10-Excellent
15. 4. Occupational Functioning (able to carry out work, school, and parenting duties)

    1. 1-Poor
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8
    9. 9
    10. 10-Excellent
17. 5. Interpersonal Functioning (able to respond and relate well to family, friends, and groups)

    1. 1-Poor
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8
    9. 9
    10. 10-Excellent
19. 6. Social-Emotional Support (availability of people you can trust and who can offer help and emotional support)

    1. 1-Poor
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8
    9. 9
    10. 10-Excellent
21. 7. Community and Services Support (pleasant and safe neighborhood, access to financial, informational, and other resources)

    1. 1-Poor
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8
    9. 9
    10. 10-Excellent
23. 8. Personal Fulfillment (experiencing a sense of balance, pride, and satisfaction; finding joy in life; doing things that make me happy)

    1. 1-Poor
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8
    9. 9
    10. 10-Excellent
25. 9. Spiritual Fulfillment (experiencing faith, religion, or other spiritual happiness beyond my material possessions)

    1. 1-Poor
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8
    9. 9
    10. 10-Excellent
27. 10. General Perception of Quality of Life (feeling satisfied and happy with your life in general)

    1. 1-Poor
    2. 2
    3. 3
    4. 4
    5. 5
    6. 6
    7. 7
    8. 8
    9. 9
    10. 10-Excellent
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