The Veterans Rand 12-Item Health Survey (VR-12)

_{OMB 0925-0589}

_{Expiration Date: xx/xx/20xx}

Public reporting burden for this collection of information is estimated to be 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589). Do not return the completed form to this address.

THE VETERANS RAND 12-ITEM HEALTH SURVEY (VR-12)

This study is a collaboration between the Social Security Administration and the National Institutes of Health to develop a new method of asking questions related to disability (i.e., computer adaptive tests) and new questions to ask about your daily physical and behavioral activities.

The following questions ask for your views about your health—how you feel and how well you are able to do your usual activities. All kinds of people across the country are being asked these same questions. Their answers and yours will help to improve health care for everyone. There are no right or wrong answers; please choose the answer that best fits your life right now.

Answer each question by marking an ‘X’ next to the best response. For example:

What is your gender?

 Male

 Female

Q1. In general, would you say your health is:

 Excellent

 Very good

 Good

 Fair

_{ Poor}

Q2. 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?

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

 Yes, limited a lot

 Yes, limited a little

 No, not limited at all

b. Climbing several flights of stairs?

 Yes, limited a lot

 Yes, limited a little

_{ No, not limited at all}

Q3. 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?

a. Accomplished less than you would like.

 No, none of the time

 Yes, a little of the time

 Yes, some of the time

 Yes, most of the time

 Yes, all of the time

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

 No, none of the time

 Yes, a little of the time

 Yes, some of the time

 Yes, most of the time

 Yes, all of the time

Q4. 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 (such as feeling depressed or anxious)?

a. Accomplished less than you would like.

 No, none of the time

 Yes, a little of the time

 Yes, some of the time

 Yes, most of the time

 Yes, all of the time

b. Didn’t do work or other activities as carefully as usual.

 No, none of the time

 Yes, a little of the time

 Yes, some of the time

 Yes, most of the time

 Yes, all of the time

Continue to next page

Q5. 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

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.

_{Q6a. How much of the time during the past 4 weeks:}

Have you felt calm and peaceful?

 All of the time

 Most of the time

 A good bit of the time

 Some of the time

 A little of the time

 None of the time

_{Q6b. How much of the time during the past 4 weeks:}

Did you have a lot of energy?

 All of the time

 Most of the time

 A good bit of the time

 Some of the time

 A little of the time

 None of the time

_{Q6c. How much of the time during the past 4 weeks:}

Have you felt downhearted and blue?

 All of the time

 Most of the time

 A good bit of the time

 Some of the time

 A little of the time

_{ None of the time}

Continue to next page

Q7. 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.)?

 All of the time

 Most of the time

 Some of the time

 A little of the time

 None of the time

Now, we’d like to ask you some questions about how your health may have changed.

Q8. Compared to one year ago, how would you rate your physical health in general now?

 Much better

 Slightly better

 About the same

 Slightly worse

 Much worse

Q9. Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) now?

 Much better

 Slightly better

 About the same

 Slightly worse

_{ Much worse}

Your answers are important!

_{Thank you for completing this questionnaire!}

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