SF36 Health Survey

INSTRUCTIONS: This set of questions asks for your views about your health. This information
will help keep track of how you feel and how well you are able to do your usual activities. Answer
every question by marking 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: (Please tick one box.)
Excellent
Very Good
Good
Fair
Poor
Compared to one year ago, how would you rate your health in general now? (Please tick one box.)
2.
Much better 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
The following questions are about activities you might do during a typical day. Does your health
3.
now limit you in these activities? If so, how much? (Please circle one number on each line.)
Yes, Yes, Not
Limited Limited A Limited
Activities
A Lot Little At All
3(a) Vigorous activities, such as running, lifting heavy objects, 1 2 3
participating in strenuous sports
3(b) Moderate activities, such as moving a table, pushing a 1 2 3
vacuum cleaner, bowling, or playing golf
3(c) Lifting or carrying groceries 1 2 3
3(d) Climbing several flights of stairs 1 2 3
3(e) Climbing one flight of stairs 1 2 3
3(f) Bending, kneeling, or stooping 1 2 3
3(g) Waling more than a mile 1 2 3
3(h) Walking several blocks 1 2 3
3(i) Walking one block 1 2 3
3(j) Bathing or dressing yourself 1 2 3
4. During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of your physical health?
(Please circle one number on each line.) Yes No
4(a) Cut down on the amount of time you spent on work or other activities 1 2
4(b) Accomplished less than you would like 1 2
4(c) Were limited in the kind of work or other activities 1 2
4(d) Had difficulty performing the work or other activities (for example, it took 1 2
extra effort)
5. During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of any emotional problems (e.g. feeling depressed or anxious)?
(Please circle one number on each line.) Yes No
5(a) Cut down on the amount of time you spent on work or other activities 1 2
5(b) Accomplished less than you would like 1 2
5(c) Didnt do work or other activities as carefully as usual 1 2
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, neighbours, or groups? (Please tick one box.)
Not at all
Slightly
Moderately
Quite a bit
Extremely

7. How much physical pain have you had during the past 4 weeks? (Please tick one box.)
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)? (Please tick one box.)
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. Please give the one answer that is closest to the way you have been feeling for each item.
All of Most A Good Some A Little None
(Please circle one number on each line.) the of the Bit of of the of the of the
Time Time the Time Time Time Time
9(a) Did you feel full of life? 1 2 3 4 5 6
9(b) Have you been a very nervous person? 1 2 3 4 5 6
9(c) Have you felt so down in the dumps that 1 2 3 4 5 6
nothing could cheer you up?
9(d) Have you felt calm and peaceful? 1 2 3 4 5 6
9(e) Did you have a lot of energy? 1 2 3 4 5 6
9(f) Have you felt downhearted and blue? 1 2 3 4 5 6
9(g) Did you feel worn out? 1 2 3 4 5 6
9(h) Have you been a happy person? 1 2 3 4 5 6
9(i) Did you feel tired? 1 2 3 4 5 6
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 with friends, relatives etc.) (Please tick one box.)
All of the time
Most of the time
Some of the time
A little of the time
None of the time
How TRUE or FALSE is each of the following statements for you?
11.
(Please circle one number on each line.) Definitely Mostly Dont Mostly Definitely
True True Know False False
11(a) I seem to get sick a little easier than 1 2 3 4 5
other people
11(b) I am as healthy as anybody I know 1 2 3 4 5
11(c) I expect my health to get worse 1 2 3 4 5
11(d) My health is excellent 1 2 3 4 5
Thank You!