SF-36v2 Health Survey

Your Health in General
1. In general‚ would you say your health is:
Excellent‚ Very good‚ Good‚ Fair‚ Poor
2. Compared to one year ago‚ how would you rate your health in general now?
Much better now than one year ago‚ Somewhat better now than one year ago‚ About the same as one year ago‚ Somewhat worse now than one year ago‚ Much worse now than one year ago
3. 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?
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
a) Vigorous activities‚ such as running‚ lifting heavy objects‚ participating in strenuous sports
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
b) Moderate activities‚ such as moving a table‚ pushing a vacuum cleaner‚ bowling‚ or playing golf
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
c) Lifting or carrying groceries
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
d) Climbing several flights of stairs
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
e) Climbing one flight of stairs
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
f) Bending‚ kneeling‚ or stooping
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
g) Walking more than a mile
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
h) Walking several hundred yards
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
i) Walking one hundred yards
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
j) Bathing or dressing yourself
Yes‚ limited a lot
Yes‚ limited a little
No‚ not limited at all
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 your physical health?
a) Cut down on the amount of time you spent on work or other activities
All of the time
Most of the time
Some of the time
A little of the time
None of the time
b) Accomplished less than you would like
All of the time
Most of the time
Some of the time
A little of the time
None of the time
c) Were limited in the kind of work or other activities
All of the time
Most of the time
Some of the time
A little of the time
None of the time
d) Had difficulty performing the work or other activities (for example‚ it took extra effort)
All of the time
Most of the time
Some of the time
A little of the time
None of the time
5. 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) Cut down on the amount of time you spent on work or other activities
All of the time
Most of the time
Some of the time
A little of the time
None of the time
b) Accomplished less than you would like
All of the time
Most of the time
Some of the time
A little of the time
None of the time
c) Did work or other activities less carefullythan usual
All of the time
Most of the time
Some of the time
A little of the time
None of the time
6. During the past 4 weeks‚ to what extent has your physical health or emotional problems interfered with your normal social activities with family‚ friends‚ neighbors‚ or groups?
Not at all
Slightly
Moderately
Quite a bit
Extremely
7. How much bodily pain have you had during the past 4 weeks?
None
Very mild
Mild
Moderate
Severe
Very severe
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
A little bit
Moderately
Quite a bit
Extremely
9. 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) did you feel full of life?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
b) have you been very nervous?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
c) have you felt so down in the dumps that nothing could cheer you up?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
d) have you felt calm and peaceful?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
e) did you have a lot of energy?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
f) have you felt downhearted and depressed?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
g) did you feel worn out?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
h) have you been happy?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
i) did you feel tired?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
10. 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
Most of the time
Some of the time
A little of the time
None of the time
11. How TRUE or FALSE is each of the following statements for you?
a) I seem to get sick a little easier than other people
Definitely true
Mostly true
Don’t know
Mostly false
Definitely false
b) I am as healthy as anybody I know
Definitely true
Mostly true
Don’t know
Mostly false
Definitely false
c) I expect my health to get worse
Definitely true
Mostly true
Don’t know
Mostly false
Definitely false
d) My health is excellent
Definitely true
Mostly true
Don’t know
Mostly false
Definitely false
 
 
Physical Functioning‚ Role-Physical‚ Role-Emotional (role of emotional functioning on daily life)‚ Bodily Pain‚ General Health‚ Vitality (energy/fatigue)‚ Social Functioning‚ Mental Health (nervousness and depression)
 
This instrument can be found on Medical Outcomes Study: 36-Item Short Form Survey Instrument. Available online at: http://www.rand.org/health/surveys_tools/mos/mos_core_36item_survey.html & http://www.sf-36.org/tools/sf36.shtml#LIT
 
1 = Strongly disagree‚ 2 = Somewhat disagree‚ 3 = Somewhat agree‚ 4 = Strongly agree
 

Ware‚ J.E.‚ Kosinski‚ M.‚ & Dewey‚ J.E. (2000). How to score Version Two of the SF-36 Health Survey. Lincoln‚ RI: QualityMetric Incorporated.

Ware‚ J.E.‚ Snow‚ K.K‚ & Kosinski‚ M. (2000). SF-36 Health Survey: Manual and interpretation guide. Lincoln‚ RI: QualityMetric Incorporated.

Bailey. Cara L. (2003). Designing a life of wellness‚Evaluation of the demonstration program at the Wilder Humboldt campus. Wilder Research Center. www.wilder.org