| Question | Response |
|---|---|
| Date of assessment | |
| 1. Are you currently employed (working for pay)? | NO YES |
| 2. During the past seven days, how many hours did you miss from work because of problems associated with your anemic symptoms? | |
| 3. During the past seven days, how many hours did you miss from work because of any other reason, such as vacation, holidays, time off to participate in this study? | |
| 4. During the past seven days, how many hours did you actually work? | |
| 5. During the past seven days, how much did your anemic symptoms affect your productivity while you were working? | |
| 6. During the past seven days, how much did your anemic symptoms affect your ability to do your regular daily activities, other than work at a job? |