Supplementary Quality of Life Questions

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
describes your answer.

in the one box that best

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

1

Very good

2

Good

Fair

Poor

4

5

3

2. 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

a

b

Yes,
limited
a little

No, not
limited
at all

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

1

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

2

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

3

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

1

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

2

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

3

SF-12v2™ Health Survey  1994, 2002 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF-12® a registered trademark of Medical Outcomes Trust.
(SF12v2 Standard, US Version 2.0)

3. 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

a

b

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

Most
of the
time

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

1

.......

2

........

3

.......

4

........

5

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

1

.......

2

........

3

.......

4

........

5

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 any emotional problems (such as feeling depressed or anxious)?
All of
the
time

a

b

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

Most
of the
time

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

1

........

2

.......

3

.......

4

.........

5

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

1

........

2

.......

3

.......

4

.........

5

5. 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

Extremely

4

SF-12v2™ Health Survey  1994, 2002 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF-12® a registered trademark of Medical Outcomes Trust.
(SF12v2 Standard, US Version 2.0)

5

6. 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

Some
of the
time

Most
of the
time

A little
of the
time

None
of the
time

a

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

1

.........

2

..........

3

..........

4

..........

5

b

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

1

.........

2

..........

3

..........

4

..........

5

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

1

.........

2

..........

3

..........

4

..........

5

c

7. 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

None of the
time

4

5

Thank you for completing these questions!

SF-12v2™ Health Survey  1994, 2002 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF-12® a registered trademark of Medical Outcomes Trust.
(SF12v2 Standard, US Version 2.0)