GENERAL HEALTH1. In general, would you say your health is: Excellent Very good Good Fair Poor 2. Compared to one year ago,
how would you rate your health in general now? Much better now than one year ago Somewhat better now than one year ago About the same Somewhat worse now than one year ago Much worse now than one year ago LIMITATIONS OF ACTIVITIESThe 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?3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports Yes, Limited a Lot Yes, Limited a Little No, Not limited at All 4. 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 5. Lifting or carrying groceries Yes, Limited a Lot Yes, Limited a Little No, Not limited at All 6. Climbing several flights of stairs Yes, Limited a Lot Yes, Limited a Little No, Not limited at All 7. Climbing one flight of stairs Yes, Limited a Lot Yes, Limited a Little No, Not limited at All 8. Bending, kneeling, or stooping Yes, Limited a Lot Yes, Limited a Little No, Not limited at All 9. Walking more than a mile Yes, Limited a Lot Yes, Limited a Little No, Not limited at All 10. Walking several blocks Yes, Limited a Lot Yes, Limited a Little No, Not limited at All 11. Walking one block Yes, Limited a Lot Yes, Limited a Little No, Not limited at All 12. Bathing or dressing yourself Yes, Limited a Lot Yes, Limited a Little No, Not limited at All PHYSICAL HEALTH PROBLEMSDuring 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 Yes No 14. Accomplished less than you would like Yes No 15. Were limited in the kind of work or other activities Yes No 16. Had difficulty performing the work or other activities (for example, it took extra effort) Yes No SOCIAL ACTIVITIESDuring 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)?17. Cut down the amount of time you spent on work or other activities Yes No 18. Accomplished less than you would like Yes No 19. Didn't do work or other activities as carefully as usual Yes No 20. 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? Not at all Slightly Moderately Quite a bit Extremely PAIN21. How much bodily pain have you had during the past 4 weeks? None Very Mild Mild Moderate Severe Very Severe 22. 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 Slightly Moderately Quite A Bit Extremely ENERGY AND EMOTIONSThese 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 . . . 23. Did you feel full of pep? 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 24. Have you been a very nervous person? 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 25. Have you felt so down in the dumps that nothing could cheer you up? 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 26. 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 27. 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 28. 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 29. Did you feel worn out? 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 30. Have you been a happy person? 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 31. Did you feel tired? 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 SOCIAL ACTIVITIES 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.)? 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 GENERAL HEALTHHow TRUE or FALSE is each of the following statements for you?33. I seem to get sick a little easier than other people Definitely True Mostly True Don't Know Mostly False Definitely False 34. I am as healthy as anybody I know Definitely True Mostly True Don't Know Mostly False Definitely False 35. I expect my health to get worse Definitely True Mostly True Don't Know Mostly False Definitely False 36. My health is excellent Definitely True Mostly True Don't Know Mostly False Definitely False HiddenPhysical FunctioningHiddenRole Limitations Due to Physical HealthHiddenRole Limitations Due to Emotional ProblemsHiddenEnergy FatigueHiddenEmotional Well-beingHiddenSocial FunctioningHiddenPainHiddenGeneral Health Δ
