Awe Score
Developed by the CF Unit, the Alfred Hospital, Melbourne.
THE ALFRED WELLNESS SCORE - AweScore© 2017
You are asked to report on your present state of wellness to assist in providing best healthcare. Circle the number that reflects your current state: 10 reflects your most well state ofbeing possible while zero reflects your least well state.
Name
First Name
Last Name
Email
example@example.com
I rate the amount of coughing I do each day as:
0=All the time 10= Hardly ever
I rate the amount of coughing I do each night as:
0=All the time 10=Hardly ever
I rate the amount of sputum I cough up each day as:
0=Highest 10=Lowest
I rate my level of energy as:
0=Lowest 10=Highest
I rate my level of exercise participation as:
0=Lowest 10=Highest
I rate my appetite as:
0=Poor 10=Good
I rate my weight as:
0=way off target 10=Recommended/On target
I rate my mood as:
0= Low mood/feeling flat 10= Highest/mostly cheerful
I rate my level of anxiety as:
0=Very anxious 10=Not anxious at all
I rate my sleep amount and quality as:
0=Poor 10= Excellent
I rate my general health as:
0= Poor 10=Excellent
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: