Question | |
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Q1 | In general, would you say your health is: (1 = Excellent to 5 = Poor) |
Q2 | Compared to 1 year ago, how would you rate your health in general now? (1 = Much better now than 1 year ago to 5 = Much worse now than 1 year ago) |
Q3 | 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? (1 = Yes, limited a lot to 3 = No, not limited at all) |
(a) Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports | |
(b) Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf | |
(c) Lifting or carrying groceries | |
(d) Climbing several flights of stairs | |
(e) Climbing one flight of stairs | |
(f) Bending, kneeling, or stooping | |
(g) Walking more than a mile | |
(h) Walking several hundred yards | |
(i) Walking one hundred yards | |
(j) Bathing or dressing yourself | |
Q4 | 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? (1 = All of the time to 5 = None of the time) |
(a) Cut down on the amount of time you spent on work or other activities | |
(b) Accomplished less than you would like | |
(c) Were limited in the kind of work or other activities | |
(d) Had difficulty performing the work or other activities (for example, it took extra effort) | |
Q5 | 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)? (1 = All of the time to 5 = None of the time) |
(a) Cut down on the amount of time you spent on work or other activities | |
(b) Accomplished less than you would like | |
(c) Did work or other activities less carefully than usual | |
Q6 | 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 to 5 = Extremely) |
Q7 | How much bodily pain have you had during the past 4 weeks? (1 = None to 6 = Very severe) |
Q8 | 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 to 5 = Extremely) |
Q9 | 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… (1 = All of the time to 5 = None of the time) |
(a) Did you feel full of life? | |
(b) Have you been very nervous? | |
(c) Have you felt so down in the dumps that nothing could cheer you up? | |
(d) Have you felt calm and peaceful? | |
(e) Did you have a lot of energy? | |
(f) Have you felt downhearted and depressed? | |
(f) Did you feel worn out? | |
(h) Have you been happy? | |
(i) Did you feel tired? | |
Q10 | 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.)? (1 = All of the time to 5 = None of the time) |
Q11 | How TRUE or FALSE is each of the following statements for you? (1 = Definitely true to 5 = Definitely false) |
(a) I seem to get sick a little easier than other people | |
(b) I am as healthy as anybody I know | |
(c) I expect my health to get worse | |
(d) My health is excellent |