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Client Follow Up Survey

Thank you for being part of Cape Wellness Collaborative. This survey is completely confidential and will help us improve our services. We truly appreciate your input.

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Part 1: 

Please answer the following questions:

1. How many treatments have you received from the CWC wellness practitioners using the CWC wellness card?​

2. On a scale 1 to 5 (1 meaning no improvement and 5 meaning very much improvement), how much improvement have you experienced in your symptoms due to treatments covered by CWC funding (using CWC wellness card)?​

 

Rotterdam Symptom Checklist (confidential)

In this first part of the questionnaire, you will be asked about your symptoms. Would you please, for all symptoms mentioned, indicate to what extent you have been bothered by it, by selecting the number (1 - 4) most applicable to you. The questions are related to the last week.

1 = not at all

2 = a little

3 = quite a bit

4 = very much

PLEASE ONLY RESPOND WITH A NUMBER (1, 2, 3 or 4) AND NOT A TEXT ANSWER.

Have you, during the past week, been bothered by:

A number of activities are listed below. We do not want to know whether you actually do these, only whether you are able to perform them presently. Please select the number which applies most to your condition of the past week.

1 = unable

2 = only with help

3 = without help, with difficulty

4 = without help

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Would you please check whether you answered all the questions?