SF-36 Survey
This set of questions asks for your view about your health.  This information will help keep track of how you feel and how well you are able to do you usual activities.  Answer every question by marking the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can.
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In general, would you say your health is : *
Compared to one year ago, how would you rate your health in general now? *
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?(Circle One Number on Each Line) *
Yes, Limited A Lot
Yes, Limited A Little
Not Limited At All
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
Moderate activities, such as moving a table,pushing a vacuum cleaner, bowling, or playing golf
Lifting or carrying groceries
Climbing several flights of stairs
Climbing one flight of stairs
Bending, kneeling, or stooping
Walking more than a mile
Walking several blocks
Walking one block
Bathing or dressing yourself
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?(One Choice For Each Line) *
Yes
No
. Cut down the amount of time you spent on work or other activities
Accomplished less than you would like
Were limited in the kind of work or other activities
Had difficulty performing the work or other activities (for example, it took extra 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
Cut down the amount of time you spent on work or other activities
Accomplished less than you would like
Didn't do work or other activities as carefully as usual
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? *
How much bodily pain have you had during the past 4 weeks? *
During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? *
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. (Click One Answer on Each Line)                                                        How much of the time during the past 4 weeks . . . *
All 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
Did you feel full of pep?
Have you been a very nervous person?
Have you felt so down in the dumps that nothing could cheer you up?
Have you felt calm and peaceful?
Did you have a lot of energy?
Have you felt downhearted and blue?
Did you feel worn out?
Have you been a happy person?
Did you feel tired?
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.)?(Click One Answer) *
 How TRUE or FALSE is each of the following statements for you.  (Click One Answer on Each Line) *
Definitely True
Mostly True
Don't Know
Mostly False
Definitely False
I seem to get sick a little easier than other people
I am as healthy as anybody I know
I expect my health to get worse
My health is excellent
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