Medical Outcomes Study 20-Item Short-Form Health Survey – MOS SF-20

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

For how long (if at all) has your health limited you in: The kinds or amounts of vigorous activities you can do, like lifting heavy objects, running or participating in strenuous sports?

For how long (if at all) has your health limited you in: The kinds or amounts of moderate activities you can do, like moving a table, carrying groceries, or bowling?

For how long (if at all) has your health limited you in: Walking uphill or climbing a few flights of stairs?

For how long (if at all) has your health limited you in: Bending, lifting, or stooping?

For how long (if at all) has your health limited you in: Walking one block?

For how long (if at all) has your health limited you in: Eating, dressing, bathing, or using the toilet?

How much bodily pain have you had during the past 4 weeks?

Does your health keep you from working at a job, doing work around the house, or going to school?

Have you been unable to do certain kinds or amounts of work, housework, or schoolwork because of your health?

How much of the time, during the past month, has your health limited your social activities (like visiting with friends or close relatives)?

How much of the time, during the past month, have you been a very nervous person?

During the past month, how much of the time have you felt calm and peaceful?

How much of the time, during the past month, have you felt downhearted and blue?

During the past month, how much of the time have you been a happy person?

How often, during the past month, have you felt so down in the dumps that nothing could cheer you up?

Please rate how true or false this statement is for you: I am somewhat ill.

Please rate how true or false this statement is for you: I am as healthy as anybody I know.

Please rate how true or false this statement is for you: My health is excellent.

Please rate how true or false this statement is for you: I have been feeling bad lately.