Mode of Collection

Self-Administered
Personal Interview
Telephone Interview
Mail
Other

Patient: Date:

Score
No. Questions
1 2 3 4 5
1. In general, would you say Very
Excellent Good Fair Poor
your health is Good
2. Compared to 1 Year Ago, Much Somewha About Somewhat Much
how would you rate your Better t Better the Worse Worse
health in general now? now now Same now now

The following items are about activities you might do during a typical day. Does
your health now limit you in these activities? If so, how much?
Score
No
Questions Yes limited a
. Yes limited a lot
little
3. Vigorous activities (running,
lifting heavy objects, 1 2
strenuous sports)
4. Moderate activities like
moving a table, vacuuming, 1 2
bowling, golf
5. Lifting or carrying groceries 1 2
6. Climbing several flights of
1 2
stairs
7. Climbing one flight of stairs 1 2
8. Bending, kneeling, or
1 2
stooping
9. Walking more than a mile 1 2
10. Walking several blocks 1 2
11. Walking one block 1 2
12. Bathing or dressing yourself 1 2

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?
No Score
Questions
. Yes No
13. Cut down the Amount of Time you spent on work or other
1 2
activities
14. Accomplished Less than you would like 1 2
15. Were limited in the kind of work or other activities 1 2
16. Difficulty performing work or other activities (e.g. it took
1 2
extra effort)
During the past 4 weeks, have you had any of the following problems with work or
other regular daily activities as a result of any emotional problems (such as feeling
depressed or anxious)?
No Score
Questions
. Yes No
17. Cut down the Amount of Time you spent on work or other
1 2
activities
18. Accomplished Less than you would like 1 2
19. Didn't do work or other activities as carefully as usual 1 2

Score
No. Questions
1 2 3 4 5
20. During the past 4
weeks, to what
extent has your
physical health or
emotional problems Not
Quite
interfered with your At Slightly Moderately Extremely
a Bit
normal social All
activities with
family, friends,
neighbors, or
groups?

Score
No. Questions
1 2 3 4 5 6
21. How much
bodily pain
Very Very
have you had None Mild Moderate Severe
Mild Severe
during the
past 4 weeks?

Score
No. Questions
1 2 3 4 5
22. During the past 4
weeks how much
did pain interfere
Not
with your normal Quite
At Slightly Moderately Extremely
work (including a Bit
All
both work outside
the home and
housework)?

These questions are about how you feel and how things have been with you during
the past 4 weeks. For each question, please give one answer that comes closest to the
way you have been feeling.
How Much Of The Time During The Past 4 Weeks.
No. Questions Score
 1 2 3 4 5 6
23. Did you feel full A Good A
All of Most Some None
of pep? Bit of Little
the of the of the of the
the of the
time time time time
time time
24. Have you been a A Good A
All of Most Some None
very nervous Bit of Little
the of the of the of the
person? the of the
time time time time
time time
25. Have you felt so
A Good A
down in the All of Most Some None
Bit of Little
dumps that the of the of the of the
the of the
nothing could time time time time
time time
cheer you up?
26. Have you felt A Good A
All of Most Some None
calm and Bit of Little
the of the of the of the
peaceful? the of the
time time time time
time time
27. Did you have a lot A Good A
All of Most Some None
of energy? Bit of Little
the of the of the of the
the of the
time time time time
time time
28. Have you felt A Good A
All of Most Some None
downhearted and Bit of Little
the of the of the of the
blue? the of the
time time time time
time time
29. Did you feel worn A Good A
All of Most Some None
out? Bit of Little
the of the of the of the
the of the
time time time time
time time
30. Have you been a A Good A
All of Most Some None
happy person? Bit of Little
the of the of the of the
the of the
time time time time
time time
31. Did you feel tired? A Good A
All of Most Some None
Bit of Little
the of the of the of the
the of the
time time time time
time time

Score
No. Questions
1 2 3 4 5
32. During the past 4 weeks, how
much time has your physical A
All of Most Some None
health or emotional problems Little
the of the of the of the
interfered with you social of the
time time time time
activities (like visiting friends, time
relatives, etc.)?

How True or False is each of the following statements for you?

 Score
No. Questions
1 2 3 4 5
33. I seem to get sick
Definitely Mostly Don't Mostly Definitely
a little easier than
True True Know False False
other people
34. I am as healthy as Definitely Mostly Don't Mostly Definitely
anybody I know True True Know False False
35. I expect my health Definitely Mostly Don't Mostly Definitely
to get worse True True Know False False
36. My health is Definitely Mostly Don't Mostly Definitely
excellent True True Know False False

Please answer Yes or No for each question

No Score
Questions
. Yes No
37. In the past year, have you had two weeks of more during
which you felt sad, blue, or depressed; or when you lost all
1 2
your interest or pleasure in things that you usually cared
about or enjoyed?
38. Have you had two years or more in your life when you felt
depressed or sad most days, even if you felt okay 1 2
sometimes?
39. Have you felt depressed or sad much of the time in the past
1 2
year?