Activities
Below are listed activities that each of us do or someone does for us. Thinking over the past three months, indicate to what extent you think each activity has been met by circling the appropriate number on the scale provided below. You do not have to be the one doing the activity. You are being asked to rate the extent to which each activity has been taken care of in a timely way.
1. Rarely 2. Occasionally 3. Sometimes 4. Frequently 5. Usually
Needs
Below are listed needs we all have. For each need listed, think about your life over the past three months. During this period of time, indicate to what extent you think each need has been met by circling the appropriate number on the scale provided below.
1. Rarely 2. Occasionally 3. Sometimes 4. Frequently 5. Usually
