– जेष्ठांची शाळा –

Welcome to your screening form

Name
Age
Sex
Caste/ Religion
Date of Birth
Mobile No.
Address Line 1
Address Line 2
Persons living with
Diseases

Are you basically satisfied with your life?

Deselect Answer

Have you dropped many of your activities and interests?

Deselect Answer

Do you feel that your life is empty?

Deselect Answer

Do you often get bored?

Deselect Answer

Are you in good spirits most of the time?

Deselect Answer

Are you afraid that something bad is going to happen to you?

Deselect Answer

Do you feel happy most of the time?

Deselect Answer

Do you often feel helpless?

Deselect Answer

Do you prefer to stay at home, rather than going out and doing new things?

Deselect Answer

Do you feel you have more problems with memory than most people?

Deselect Answer

Do you think it is wonderful to be alive?

Deselect Answer

Do you feel pretty worthless the way you are now?

Deselect Answer

Do you feel full of energy?

Deselect Answer

Do you feel that your situation is hopeless?

Deselect Answer

Do you think that most people are better off than you are?

Deselect Answer

Ability to Use Telephone

Deselect Answer

Shopping

Deselect Answer

Food Preparation

Deselect Answer

Housekeeping

Deselect Answer

Laundry

Deselect Answer

Mode of Transportation

Deselect Answer

Responsibility for Own Medications

Deselect Answer

Ability to Handle Finances

Deselect Answer

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