1.
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In
general, would you say your health is:
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Excellent
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Very good
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Good
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Fair
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Poor
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2.
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Compared to one year ago, how would you
rate your health in general now?
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Much better
now than one
year
ago
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Somewhat better
now than
one
year ago
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About the
same as one
year
ago
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Somewhat worse
now than
one
year ago
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Much worse
now than one
year
ago
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3.
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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?
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Yes,
limited
a
lot
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Yes,
limited
a little
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No, not limited
at all
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Public reporting burden of this collection of information is
estimated to average 30 minutes per response, including the time
for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing 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 CDC/ATSDR Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-XXXX).
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a
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Vigorous activities, such as
running, lifting heavy objects, participating in strenuous
sports
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b
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Moderate activities, such as moving
a table, pushing a vacuum cleaner, bowling, or playing golf
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c
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Lifting or carrying groceries
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d
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Climbing several flights of stairs
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e
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Climbing one flight of stairs
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f
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Bending, kneeling, or stooping
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g
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Walking more than a mile
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h
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Walking several hundred yards
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i
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Walking one hundred yards
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j
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Bathing or dressing yourself
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4.
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During the past four 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?
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All
of the time
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Most
of the time
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Some
of the time
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A little
of the time
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None
of the time
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a
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Cut down on the amount of time you
spent on work or other activities
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b
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Accomplished less than you would
like
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c
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Were limited in the kind of work or
other activities
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d
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Had difficulty performing the work
or other activities (for example, it took extra effort)
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5.
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During the past four 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)?
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All
of the time
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Most
of the time
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Some
of the time
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A little
of the time
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None
of the time
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a
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Cut down on the amount of time you
spent on work or other activities
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b
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Accomplished less than you would
like
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c
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Did work or activities less
carefully than usual
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6.
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During the past four weeks, to what
extent has your physical health or emotional problems interfered
with your normal social activities with family, friends,
neighbors, or groups?
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Not at all
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Slightly
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Moderately
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Quite a bit
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Extremely
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7.
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How much bodily pain have you had
during the past four weeks?
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None
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Very mild
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Mild
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Moderate
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Severe
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Very severe
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8.
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During the past four weeks, how much
did pain interfere with your normal work (including work outside
the home and housework)?
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Not at all
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A little bit
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Moderately
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Quite a bit
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Extremely
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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.
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All
of
the time
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Most
of
the time
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Some
of the time
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A little
of the time
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None
of the time
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a
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Did you feel full of life?
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b
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Have you been very nervous?
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c
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Have you felt so down in the dumps
that nothing could cheer you up?
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d
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Have you felt calm and peaceful?
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e
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Did you have a lot of energy?
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f
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Have you felt downhearted and
depressed?
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10.
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During the past four weeks, how much of
the time has your physical health or emotional problems
interfered with your social activities (such as visiting friends,
relatives, etc.)?
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All
of the time
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Most
of the time
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Some
of the time
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A little
of the time
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None
of the time
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11.
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How TRUE or FALSE is each of the
following statements for you?
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Definitely
true
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Mostly
true
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Don't
know
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Mostly
false
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Definitely
false
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a
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I seem to get sick a little easier
than other people
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b
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I am as healthy as anybody I know
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c
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I expect my health to get worse
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Thank you for completing these
questions!
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