Patient Questionnaire
Choose one option for each questionnaire item.
1. In general‚ would you say your health is:
1) Excellent
2) Very good
3) Good
4) Fair
5) Poor
2. For how long (if at all) has your health limited you in each of the following activities?
a. The kinds or amounts of vigorous activities you can do‚ like lifting heavy objects‚ running or participating in strenuous sports
Limited for more than 3 months (1); Limited for 3 months or less (2); Not limited at all (3)
b. The kinds or amounts of moderate activities you can do‚ like moving a table‚ carrying groceries‚ or bowling
Limited for more than 3 months (1); Limited for 3 months or less (2); Not limited at all (3)
c. Walking uphill or climbing a few flights of stairs
Limited for more than 3 months (1); Limited for 3 months or less (2); Not limited at all (3)
d. Bending‚ lifting‚ or stooping
Limited for more than 3 months (1); Limited for 3 months or less (2); Not limited at all (3)
e. Walking one block
Limited for more than 3 months (1); Limited for 3 months or less (2); Not limited at all (3)
f. Eating‚ dressing‚ bathing‚ or using the toilet
Limited for more than 3 months (1); Limited for 3 months or less (2); Not limited at all (3)
3. How much bodily pain have you had during the past 4 weeks:
1) None
2) Very mild
3) Mild
4) Moderate
5) Severe
6) Very Severe
4. Does your health keep you from working at a job‚ doing work around the house‚ or going to school?
1) YES‚ for more than 3 months
2) YES‚ for 3 months or less
3) NO
5. Have you been unable to do certain kinds or amounts of work‚ housework‚ or schoolwork because of your health?
1) YES‚ for more than 3 months
2) YES‚ for 3 months or less
3) NO
For each of the following questions‚ please mark the circle for the one answer that comes closest to the way you have been feeling during the past month.
6. How much of the time‚ during the past month‚ has you health limited your social activities (like visiting with friends or close relatives)? All of the time (1); Most of the time (2); A good bit of the time (3); Some of the time (4); A little of the time (5); None of the time (6)
7. How much of the time‚ during the past month‚ have you been a very nervous person? All of the time (1); Most of the time (2); A good bit of the time (3); Some of the time (4); A little of the time (5); None of the time (6)
8. During the past month‚ how much of the time have you felt calm and peaceful? All of the time (1); Most of the time (2); A good bit of the time (3); Some of the time (4); A little of the time (5); None of the time (6)
9. How much of the time‚ during the past month‚ have you felt downhearted and blue? All of the time (1); Most of the time (2); A good bit of the time (3); Some of the time (4); A little of the time (5); None of the time (6)
10. During the past month‚ how much of the time have you been a happy person? All of the time (1); Most of the time (2); A good bit of the time (3); Some of the time (4); A little of the time (5); None of the time (6)
11. How often‚ during the past month‚ have you felt so down in the dumps that nothing could cheer you up? All of the time (1); Most of the time (2); A good bit of the time (3); Some of the time (4); A little of the time (5); None of the time (6)
12. Please mark the circle that best describes whether each of the following statements is true or false for you.
a. I am somewhat ill
Definitely true (1); Mostly true (2); Not sure (3); Mostly false (4); Definitely false
b. I am as healthy as anybody I know
Definitely true (1); Mostly true (2); Not sure (3); Mostly false (4); Definitely false
c. My health is excellent
Definitely true (1); Mostly true (2); Not sure (3); Mostly false (4); Definitely false
d. I have been feeling bad lately
Definitely true (1); Mostly true (2); Not sure (3); Mostly false (4); Definitely false
Physical Health Composite (PCS) and Mental Health Composite (MCS)
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
