1. Do you have loss of appetite?
2. How often are you bothered by having an upset stomach?
3. Has any ill health affected the amount of work you do?
4. Have you ever felt that you were going to have a nervous breakdown?
5. Are you ever troubled by your hands sweating so that they feel damp and clammy?
6. Do you feel that you are bothered by all sorts (different kinds) of ailments in different parts of your body?
7. Do you ever have any trouble in getting to sleep and staying asleep?
8. Do your hands ever tremble enough to bother you?
9. Do you have any particular physical or health trouble?
10.Do you ever take weak turns?
11.Are you ever bothered by having nightmares? (Dreams that frighten or upset you very much?)
12.Do you smoke a lot?
13.Have you ever had spells of dizziness?
14.Have you ever been bothered by your heart beating hard?
15.Do you tend to lose weight when you have important things bothering you?
16.Are you ever bothered by nervousness?
17.Have you ever been bothered by shortness of breath when you were not exercising or working hard?
18.Do you tend to feel tired in the mornings?
19.For the most part‚ do you feel healthy enough to carry out the things that you would like to do?
20.Have you ever been troubled by “cold sweats”? (NOT a hot-sweat—you feel a chill‚ but you are sweating at the same time.)
1 (hardly ever)‚ 2 (sometimes)‚ or 3 (often).
item 16 is reverse-coded
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Semmence‚ A. M.‚ (1969).The health opinion survey A psychiatric screening instrument. J R Coll Gen Pract‚ 18(89): 344–348.
Tousignant‚ Michel.‚ Denis‚ Guy. and Lachapelle‚ Rejean. (1974). Some Considerations Concerning the Validity and Use of the Health Opinion Survey. Journal of Health and Social Behavior‚ 15(3): 241-252.
Butler‚ M. C.‚ & Jones‚ A. P. (1979). The Health Opinion Survey reconsidered: Dimensionality‚ reliability‚ and validity. Journal of Clinical Psychology‚ 35(3)‚ 554-559
McDowell‚ Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires‚ Third Edition. OXFORD UNIVERSITY PRESS