N˚

QUESTIONNAIRE

DAYS

1

How many days did you miss work (or school)?

2

On how many other days did your work productivity drop by more than 50%?

3

For how many days were you unable to carry out your usual household activities?

4

For how many days was your productivity in household chores reduced by more than 50%?

5

How many days did you miss out on family, social or leisure activities?

TOTAL