Form CMS-10728 Beneficiary Health Survey

Beneficiary Health Survey (SF-36)¹

(CMS-10728, OMB 0938-New)

The Health Survey asks 36 questions to measure functional health and well-being from the patient's point of view. It is a practical, reliable and valid measure of physical and mental health that can be completed in five to ten minutes.

Choose one option for each questionnaire item.

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

1 – Excellent

2 - Very good

3 - Good

4 – Fair

5 - Poor

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

1 - Much better now than one year ago

2 - Somewhat better now than one year ago

3 - About the same

4 - Somewhat worse now than one year ago

5 -Much worse now than one year ago

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?

	Yes, limited a lot	Yes, limited a little	No, not limited at all
3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports	1	2	3
4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf	1	2	3
5. Lifting or carrying groceries	1	2	3
6. Climbing several flights of stairs	1	2	3
7. Climbing one flight of stairs	1	2	3
8. Bending, kneeling, or stooping	1	2	3
9. Walking more than a mile	1	2	3
10. Walking several blocks	1	2	3
11. Walking one block	1	2	3
12. Bathing or dressing yourself	1	2	3

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?

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

13. Accomplished less than you would like

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

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

Yes No

1 2

1 2

1 2

1 2

effort)

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)?

Yes No

13. Cut down the amount of time you spent on work or other activities 1 2

13. Accomplished less than you would like 1 2

13. Didn't do work or other activities as carefully as usual 1 2

13. 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?

1 - Not at all

2 - Slightly

3 - Moderately

4 - Quite a bit

5 - Extremely

13. How much bodily pain have you had during the past 4 weeks?

1 - None

2 - Very mild

3 - Mild

4 - Moderate

5 - Severe

6 - Very severe

13. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

1 - Not at all

2 - A little bit

3 - Moderately 4 - Quite a bit

5 - 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.

How much of the time during the past 4 weeks...

	All of	Most	A good	Some	A little	None
	the	of the	bit of the	of the	of the	of the
	time	time	time	time	time	time
23. Did you feel full of pep?	1	2	3	4	5	6
24. Have you been a very nervous person?	1	2	3	4	5	6
25. Have you felt so down in the dumps that nothing could cheer you up?	1	2	3	4	5	6
26. Have you felt calm and peaceful?	1	2	3	4	5	6
27. Did you have a lot of energy?	1	2	3	4	5	6
28. Have you felt downhearted and blue?	1	2	3	4	5	6
29. Did you feel worn out?	1	2	3	4	5	6
30. Have you been a happy person?	1	2	3	4	5	6
31. Did you feel tired?	1	2	3	4	5	6

32. 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.)?

1 - All of the time

2 - Most of the time

3 - Some of the time

4 - A little of the time

5 - None of the time

How TRUE or FALSE is each of the following statements for you.

	Definitely true	Mostly true	Don't know	Mostly false	Definitely false
33. I seem to get sick a little easier than other people	1	2	3	4	5
34. I am as healthy as anybody I know	1	2	3	4	5
35. I expect my health to get worse	1	2	3	4	5
36. My health is excellent	1	2	3	4	5

According the Paperwork Reduction Act of 1995 (PRA), no persons are required to respond to a collection of information unless such a collection displays a valid OMB Control number. CMS/CMMI is required by the PRA to inform demonstration beneficiaries that the collection of this survey’s information is required and take approximately 5-10 minutes to review the instructions and to complete and submit the survey. Any comments regarding the burden or other aspects of this collection of information, including suggestions for reducing burden, must be sent to Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop WB-06-05 Baltimore, Maryland 21244.

1 Acknowledgement: The 36 – Item Short- Form (SF-36) was developed by RAND as part of the Medical Outcomes Study.

Appendix A