SF-36v2TM Health Survey
This survey asks for your views about your health. This information will help you keep track of how you feel and how well you are able to do your usual activities.

Answer every question by selecting the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can.


1.  In general, would you say your health is: [Click on the circle that best describes your answer.]
 
  Excellent Very Good Good Fair Poor
 
 
2.  Compared to one year ago, how would you rate your health in general now?
 
  Much better
now than one
year ago		 Somewhat better
now than one
year ago		 About the
same as one
year ago		 Somewhat worse
now than one
year ago		 Much worse
now than one
year ago
 
 
3.  The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? [Click on a circle on each line.]
  Yes,
limited
a lot		 Yes,
limited
a little		 No, not
limited
at all
  a.  Vigorous Activities, such as running, lifting heavy objects, participating in strenuous sports
 
  b.  Moderate Activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
 
  c.  Lifting or carrying groceries
  d.  Climbing several flights of stairs
  e.  Climbing one flight of stairs
  f.  Bending, kneeling, or stooping
  g.  Walking more than a mile
  h.  Walking several hundred yards
  i.  Walking one hundred yards
  j.  Bathing or dressing yourself
 
4.  During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
 
  All of
the time		 Most of
the time		 Some of
the time		 A little of
the time		 None of
the time
  a.  Cut down on the amount of time you spent on work or other activities
 
  b.  Accomplished less than you would like
  c.  Were limited in the kind of work or other activities
  d.  Had difficulty performing the work or other activities (for example, it took extra effort)
 
5.  During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
 
  All of
the time		 Most of
the time		 Some of
the time		 A little of
the time		 None of
the time
  a.  Cut down on the amount of time you spent on work or other activities
 
  b.  Accomplished less than you would like
  c.  Did work or activities less carefully than usual
 
6.  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?
 
  Not at all Slightly Moderately Quite a bit Extremely
 
 
7.  How much bodily pain have you had during the past 4 weeks?
 
  None Very Mild Mild Moderate Severe Very Severe
 
 
8.  During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
 
  Not at all A little bit Moderately Quite a bit Extremely
 
 
9.  These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
 
How much of the time during the past 4 weeks...
  All of
the time		 Most of
the time		 Some of
the time		 A little of
the time		 None of
the time
  a.  Did you feel full of life?
  b.  Have you been very nervous?
  c.  Have you felt so down in the dumps that nothing could cheer you up?
 
  d.  Have you felt calm and peaceful?
  e.  Did you have a lot of energy?
  f.  Have you felt downhearted and depressed?
  g.  Did you feel worn out?
  h.  Have you been happy?
  i.  Did you feel tired?
 
10.  During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?
 
  All of
the time		 Most of
the time		 Some of
the time		 A little of
the time		 None of
the time
   
 
11.  How TRUE or FALSE is each of the following statements for you?
 
  Definitely
true		 Mostly
true		 Don't
Know		 Mostly
false		 Definitely
false
  a.  I seem to get sick a little easier than other people
 
  b.  I am as healthy as anybody I know
  c.  I expect my health to get worse
  d.  My health is excellent