Practice form

This is only a practice. Try filling it in, then send it back to Leon. There are no wrong answers.

1. Today's date

Type the date.

2. How did you sleep last night?

Pick one.

Very well Well Not well Badly

3. In the past week, how often did you have a headache?

Pick one.

0 Never 1 Sometimes, mild 2 Sometimes, strong 3 Often, mild 4 Often, strong

4. In the past week, how often did you feel tired?

Pick one.

0 Never 1 Sometimes, mild 2 Sometimes, strong 3 Often, mild 4 Often, strong

5. Did you go for a walk today?

Pick one.

Yes No

6. Which of these did you eat today?

Tick all that apply.

Fruit Vegetables Bread Fish Something sweet

7. How many glasses of water did you drink today?

Type a number.

8. Is there anything else you would like Leon to know?

Type a few sentences.

If the buttons don't respond, tell Leon.