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| Do you feel that your health has gotten worse over the past 2 years? |
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| Have you lost or gained more than 10% of your body weight over the past 5 years—even though you weren’t intentionally dieting? |
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| Do you have trouble going to sleep or staying asleep? |
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| Does pain in your joints or muscles limit your physical activity or mobility? |
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| Do you commonly feel fatigued for no apparent reason? |
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| Are you frequently depressed or anxious? |
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| Do you have problems with memory? |
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| Is there a consistent ringing in your ears? |
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| Do you feel that you are losing your strength? |
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| Do you take any prescription medications? Do you take more than 2? |
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