| Very poor | Poor | Neither poor nor good | Good | Very good | |
| 1. How would you rate your quality of life? | 1 | 2 | 3 | 4 | 5 |
| Very dissatisfied | Dissatisfied | Neither satisfied nor dissatisfied |
Satisfied | Very satisfied | |
| 2. How satisfied are you with your health? | 1 | 2 | 3 | 4 | 5 |