Form No number No number Medical Outcomes Study Short Form

Your Health and Well-Being
This survey 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. Thank you for completing this survey!
For each of the following questions, please mark an
best describes your answer.

in the one box that

1. In general, would you say your health is:

Excellent

1

Very good

2

Good

3

Fair

Poor

4

5

2. Compared to one year ago, how would you rate your health in general

Much better
now than one
year ago

1

Somewhat
better now
than one year
ago

2

About the
same as one
year ago

3

Somewhat
worse now
than one year
ago

4

Much worse
now than one
year ago

5

SF-36v2™ Health Survey  1996, 2000 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF-36® is a registered trademark of Medical Outcomes Trust.
(SF-36v2 Standard, US Version 2.0)

now?

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?

Yes,
limited
a lot

Vigorous activities, such as running, lifting
heavy objects, participating in strenuous
sports ....................................................................

1

Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or
playing golf..............................................................

1

c

Lifting or carrying groceries ......................................

1

d

Climbing several flights of stairs.................................

1

e

Climbing one flight of stairs........................................

1

f

Bending, kneeling, or stooping...................................

1

g

Walking more than a mile..........................................

1

h

Walking several hundred yards..................................

1

i

Walking one hundred yards.......................................

1

j

Bathing or dressing yourself.......................................

1

a

b

Yes,
limited
a little

No, not
limited
at all

...................

2

...................

3

...................

2

...................

3

...................

2

...................

3

...................

2

...................

3

...................

2

...................

3

...................

2

...................

3

...................

2

...................

3

...................

2

...................

3

...................

2

...................

3

...................

2

...................

3

SF-36v2™ Health Survey  1996, 2000 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF-36® is a registered trademark of Medical Outcomes Trust.
(SF-36v2 Standard, US Version 2.0)

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 Most of Some of A little of None of
time
the time the time the time the time

a

b

c

d

Cut down on the amount of time you spent
on work or other activities...........................................

1

Accomplished less than you would like .......................

1

Were limited in the kind of work or other
activities....................................................................

1

Had difficulty performing the work or other
activities (for example, it took extra effort) .................

1

.........

2

.........

3

.........

2

.........

3

.........

2

.........

3

.........

2

.........

3

..........

4

..........

4

..........

4

..........

4

.........

5

.........

5

.........

5

.........

5

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 Most of Some of A little of None of
time
the time the time the time the time

a

b

c

Cut down on the amount of time you spent
on work or other activities .......................................

1

.........

2

.........

3

Accomplished less than you would like.....................

1

.........

2

.........

3

Did work or other activities less carefully
than usual................................................................

1

.........

2

.........

3

..........

4

..........

4

..........

4

SF-36v2™ Health Survey  1996, 2000 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF-36® is a registered trademark of Medical Outcomes Trust.
(SF-36v2 Standard, US Version 2.0)

.........

5

.........

5

.........

5

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

1

Slightly

Moderately

2

Quite a bit

3

Extremely

4

5

7. How much bodily pain have you had during the past 4 weeks?
None

1

Very mild

2

Mild

Moderate

3

4

Severe

Very Severe

5

6

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

1

A little bit

2

Moderately

3

Quite a bit

4

Extremely

5

SF-36v2™ Health Survey  1996, 2000 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF-36® is a registered trademark of Medical Outcomes Trust.
(SF-36v2 Standard, US Version 2.0)

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 Most of Some of A little of None of
time
the time the time the time the time

a

Did you feel full of life?...........................................

1

b

Have you been very nervous?.................................

1

Have you felt so down in the dumps
that nothing could cheer you up?.............................

1

d

Have you felt calm and peaceful?............................

1

e

Did you have a lot of energy? .................................

1

Have you felt downhearted and
depressed? ............................................................

1

g

Did you feel worn out?...........................................

1

h

Have you been happy?...........................................

1

i

Did you feel tired? ..................................................

1

c

f

..........

2

..........

3

..........

2

..........

3

..........

2

..........

3

..........

2

..........

3

..........

2

..........

3

..........

2

..........

3

..........

2

..........

3

..........

2

..........

3

..........

2

..........

3

..........

4

..........

5

..........

4

..........

5

..........

4

..........

5

..........

4

..........

5

..........

4

..........

5

..........

4

..........

5

..........

4

..........

5

..........

4

..........

5

..........

4

..........

5

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

1

Most of the
time

2

Some of the
time

3

A little of the
time

4

None of the
time

5

SF-36v2™ Health Survey  1996, 2000 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF-36® is a registered trademark of Medical Outcomes Trust.
(SF-36v2 Standard, US Version 2.0)

11. How TRUE or FALSE is each of the following statements for you?
Definitely
true

Mostly
true

Don't
know

Mostly
false

Definitely
false

I seem to get sick a little easier
than other people .....................................

1

............

2

...........

8

...........

3

...........

4

b

I am as healthy as anybody I know...........

1

............

2

...........

8

...........

3

...........

4

c

I expect my health to get worse ................

1

............

2

...........

8

...........

3

...........

4

d

My health is excellent ...............................

1

............

2

...........

8

...........

3

...........

4

a

THANK YOU FOR COMPLETING THESE QUESTIONS!

SF-36v2™ Health Survey  1996, 2000 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF-36® is a registered trademark of Medical Outcomes Trust.
(SF-36v2 Standard, US Version 2.0)