RAND 12-Item Short Form Health Survey – SF-12

In general, would you say your health is: (Excellent, Very Good, Good, Fair, Poor)

Does your health now limit you in moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?

Does your health now limit you in climbing several flights of stairs?

During the past 4 weeks, have you accomplished less than you would like as a result of your physical health?

During the past 4 weeks, were you limited in the kind of work or other activities as a result of your physical health?

During the past 4 weeks, have you accomplished less than you would like as a result of any emotional problems (such as feeling depressed or anxious)?

During the past 4 weeks, did you do work or other activities less carefully than usual as a result of any emotional problems (such as feeling depressed or anxious)?

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

How much of the time during the past 4 weeks have you felt calm and peaceful?

How much of the time during the past 4 weeks did you have a lot of energy?

How much of the time during the past 4 weeks have you felt downhearted and depressed?

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.)?