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? (Yes, Limited A Lot; Yes, Limited A Little; No, Not Limited At All)

Does your health now limit you in climbing several flights of stairs? (Yes, Limited A Lot; Yes, Limited A Little; No, Not Limited At All)

During the past 4 weeks, have you accomplished less than you would like as a result of your physical health? (Yes / No)

During the past 4 weeks, were you limited in the kind of work or other activities as a result of your physical health? (Yes / No)

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)? (Yes / No)

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)? (Yes / No)

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, A little bit, Moderately, Quite a bit, Extremely)

How much of the time during the past 4 weeks have you felt calm and peaceful? (All of the Time, Most of the Time, Some of the Time, A Little of the Time, None of the Time)

How much of the time during the past 4 weeks did you have a lot of energy? (All of the Time, Most of the Time, Some of the Time, A Little of the Time, None of the Time)

How much of the time during the past 4 weeks have you felt downhearted and depressed? (All of the Time, Most of the Time, Some of the Time, A Little of the Time, None of the Time)

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.)? (All of the Time, Most of the Time, Some of the Time, A Little of the Time, None of the Time)