Pre-Assessment Pre-Assessment First Name *Last Name *Birthday *Race *WhiteBlack or African AmericanAmerican Indian and Alaska NativeAsianNative Hawaiian and Other Pacific IslanderHispanic or LatinoTwo or more racesPlease chose only one.Are you a combat veteran? *YesNoWars/conflicts: *Please select the statements that best describe you. You may chose more than one. *I am unemployed and I am not looking for work at this time.I am unemployed and I am looking for work at this time.I am employed but I do not enjoy my work.I am employed and I enjoy my work.I am retired.I am retired but still looking for some work.I volunteer in my community.Please think back over the last two weeks and answer these questions honestly by putting a check mark in the box which corresponds with your answer. Please only choose one box. This tool is used to see if and how receiving dental care changes how you feel about your life over the following categories: mental health, social satisfaction, and employment/economic satisfaction.Dental pain keeps me from doing the things I love. *Not at allSeveral daysMore than half the weekNearly every dayI am satisfied with my current state of health. *Not at allSeveral daysMore than half the weekNearly every dayI am able to eat a healthy, well-balanced diet with a variety of meats, fruits, and vegetables. *Not at allSeveral daysMore than half the weekNearly every dayI want to try new things. *Not at allSeveral daysMore than half the weekNearly every dayI engage in social activities. *Not at allSeveral daysMore than half the weekNearly every dayI enjoy spending time with other people. *Not at allSeveral daysMore than half the weekNearly every dayI am able to laugh and see the funny side of things. *Not at allSeveral daysMore than half the weekNearly every dayI spend time talking to friends or family. *Not at allSeveral daysMore than half the weekNearly every dayI am able to have fun and am excited about the things in my life. *Not at allSeveral daysMore than half the weekNearly every dayI sleep well and wake up well-rested. *Not at allSeveral daysMore than half the weekNearly every dayI have felt sad or miserable. *Not at allSeveral daysMore than half the weekNearly every dayI think the world would be better off without me. *Not at allSeveral daysMore than half the weekNearly every dayI have thoughts of harming myself. *Not at allSeveral daysMore than half the weekNearly every dayI have been anxious or worried for no reason. *Not at allSeveral daysMore than half the weekNearly every dayLife has troubles, but I feel I am coping well. *Not at allSeveral daysMore than half the weekNearly every dayI feel hopeful about my future. *Not at allSeveral daysMore than half the weekNearly every dayAdditional Comments:Consent *I give AAVD consent to use my comments in marketing materials.Submit
