36-Item Short Form Survey Instrument(SF-36)Please read each of the following questions carefully and select your answer. Each question is required. Name * First Name Last Name Email * 1. In general, would you say your health is: 1 - Excellent 2 - Very good 3 - Good 4 - Fair 5 - Poor 2. Compared to one year ago, how would you rate your health in general now? 1 - Much better now than one year ago 2 - Somewhat better now than one year ago 3 - About the same 4 - Somewhat worse now than one year ago 5 - Much worse now than one year ago 3. The following question is about an activity you might do during a typical day. Does your health now limit you in this activity? If so, how much? Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 4. The following question is about an activity you might do during a typical day. Does your health now limit you in this activity? If so, how much? Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 5. The following question is about an activity you might do during a typical day. Does your health now limit you in this activity? If so, how much? Lifting or carrying groceries Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 6. The following question is about an activity you might do during a typical day. Does your health now limit you in this activity? If so, how much? Climbing several flights of stairs Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 7. The following question is about an activity you might do during a typical day. Does your health now limit you in this activity? If so, how much? Climbing one flight of stairs Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 8. The following question is about an activity you might do during a typical day. Does your health now limit you in this activity? If so, how much? Bending, kneeling, or stooping Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 9. The following question is about an activity you might do during a typical day. Does your health now limit you in this activity? If so, how much? Walking more than a mile Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 10. The following question is about an activity you might do during a typical day. Does your health now limit you in this activity? If so, how much? Walking several blocks Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 11. The following question is about an activity you might do during a typical day. Does your health now limit you in this activity? If so, how much? Walking one block Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 12. The following question is about an activity you might do during a typical day. Does your health now limit you in this activity? If so, how much? Bathing or dressing yourself Yes, limited a lot (1) Yes, limited a little (2) No, not limited at all (3) 13. During the past 4 weeks, have you experienced the following problem as a result of your physical health? Cut down the amount of time you spent on work or other activities Yes No 14. During the past 4 weeks, have you experienced the following problem as a result of your physical health? Accomplished less than you would like Yes No 15. During the past 4 weeks, have you experienced the following problem as a result of your physical health? Were limited in the kind of work or other activities Yes No 16. During the past 4 weeks, have you experienced the following problem as a result of your physical health? Had difficulty performing the work or other activities (for example, it took extra effort) Yes No 17. During the past 4 weeks, have you had the following problem with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? Cut down the amount of time you spent on work or other activities Yes No 18. During the past 4 weeks, have you had the following problem with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? Accomplished less than you would like Yes No 19. During the past 4 weeks, have you had the following problem with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? Didn't do work or other activities as carefully as usual Yes No 20. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? 1 - Not at all 2 - Slightly 3 - Moderately 4 - Quite a bit 5 - Extremely 21. How much bodily pain have you had during the past 4 weeks? 1 - None 2 - Very mild 3 - Mild 4 - Moderate 5 - Severe 6 - Very severe 23. How much of the time during the past 4 weeks... Did you feel full of pep? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 24. How much of the time during the past 4 weeks... 24. Have you been a very nervous person? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 25. How much of the time during the past 4 weeks... Have you felt so down in the dumps that nothing could cheer you up? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 26. How much of the time during the past 4 weeks... Have you felt calm and peaceful? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 27. How much of the time during the past 4 weeks... Did you have a lot of energy? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 28. How much of the time during the past 4 weeks... Have you felt downhearted and blue? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 29. How much of the time during the past 4 weeks... * Did you feel worn out? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 30. How much of the time during the past 4 weeks... * Have you been a happy person? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 31. How much of the time during the past 4 weeks... * Did you feel tired? All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 32. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? * All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6) 33. How TRUE or FALSE is the following statement for you. * I seem to get sick a little easier than other people Definitely true (1) Mostly true (2) Don't know (3) Mostly false (4) Definitely false (5) 34. How TRUE or FALSE is the following statement for you. * I am as healthy as anybody I know Definitely true (1) Mostly true (2) Don't know (3) Mostly false (4) Definitely false (5) 35. How TRUE or FALSE is the following statement for you. * I expect my health to get worse Definitely true (1) Mostly true (2) Don't know (3) Mostly false (4) Definitely false (5) 36. How TRUE or FALSE is the following statement for you. * My health is excellent Definitely true (1) Mostly true (2) Don't know (3) Mostly false (4) Definitely false (5) Thank you!
