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)
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       
 

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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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