RAND Medical Outcomes Study -12

For each of the following questions‚ please mark an X in the one box that best describes your answer.
1. In general‚ would you say your health is:
Excellent (1)‚ Very Good (2)‚ Good (3)‚ Fair (4)‚ Poor (5)
2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so‚ how much?
a.    Moderate activities‚ such as moving a table‚ pushing a vacuum cleaner‚ bowling‚ or playing golf
Yes‚ Limited A Lot (1); Yes‚ Limited A Little (2); No‚ Not Limited At All (3)
b.    Climbing several flights of stairs
Yes‚ Limited A Lot (1); Yes‚ Limited A Little (2); No‚ Not Limited At All (3)
3. During the past 4 weeks‚ how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
a.    Accomplished less than you would like
All of the Time (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
b.    Were limited in the kind of work or other activities
All of the Time (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
4. During the past 4 weeks‚ how much of the time 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)?
a.    Accomplished less than you would like
All of the Time (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
b.    Did work or other activities less carefully than usual
All of the Time (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time (5)
5. 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 (1); A little bit (2); Moderately (3); Quite a bit (4); Extremely (5)
6. These 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 . . .
a.    Have you felt calm and peaceful?
All of the Time (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
b.    Did you have a lot of energy?
All of the Time (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
c.    Have you felt downhearted and depressed?
All of the Time (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
7. 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 (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
نسخه ای دیگر
1.    In general‚ would you say your health is:
Excellent (1)‚ Very Good (2)‚ Good (3)‚ Fair (4)‚ Poor (5)
The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so‚ how much?
2.    Moderate activities‚ such as moving a table‚ pushing a vacuum cleaner‚ bowling‚ or playing golf
Yes‚ Limited A Lot (1); Yes‚ Limited A Little (2); No‚ Not Limited At All (3)
3.    Climbing several flights of stairs
Yes‚ Limited A Lot (1); Yes‚ Limited A Little (2); No‚ Not Limited At All (3)
During the past 4 weeks‚ how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
4.    Accomplished less than you would like
YES ; NO
5.    Were limited in the kind of work or other activities
YES ; NO
During the past 4 weeks‚ how much of the time 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)?
6.    Accomplished less than you would like
YES ; NO
7.    Did work or other activities less carefully than usual
YES ; NO
8.    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 (1); A little bit (2); Moderately (3); Quite a bit (4); Extremely (5)
These 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 . . .
9.    Have you felt calm and peaceful?
All of the Time (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
10.Did you have a lot of energy?
All of the Time (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
11.Have you felt downhearted and depressed?
All of the Time (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
12.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 (1); Most of the Time (2); Some of the Time (3); A Little of the Time (4); None of the Time(5)
 
Physical Health Composite (PCS) and Mental Health Composite (MCS)
 
Reverse items          1‚ 8‚ 9‚ and 10       
 
 

Stewart‚ A.L.‚ Hays‚ R.D.‚ Ware‚ J.E‚ Jr. (1992). Health perceptions‚ energy/fatigue‚ and health distress measures. In: Stewart AL‚ Ware JE‚ Jr.‚ eds. Measuring functioning and wellbeing: the Medical Outcomes Study approach. Durham‚ NC: Duke University Press‚ 143–172.

Ware‚ J.E‚ Jr.‚ Kosinski‚ M.‚ Keller‚ S.D. (1995). How to score the SF-12 physical and mental health summary scales. Boston: The Health Institute‚ New England Medical Center.

Ware‚ J.E‚ Jr.‚ Kosinski‚ M.‚ Keller‚ SD. (1996). A 12- Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care‚ 34:220–233.

Ware‚ J.E‚ Jr.‚ Kosinski‚ M.‚ Turner-Bowker‚ D.M.‚ et al. (2002). How to score Version 2 of the SF-12 et al. Health Survey. Lincoln‚ Rhode Island: QualityMetric Inc.

Bennett‚ S.J.‚ Oldridge‚ N.B.‚ Eckert‚ G.J.‚ et al. (2002). Discriminant properties of commonly used quality of life measures in heart failure.Qual Life Res‚ 11:349–359.

McDowell‚ Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires‚ Third Edition. OXFORD UNIVERSITY PRESS

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