RAND SF-36-Item Health Survey

RAND SF-36-Item Health Survey

1. In general, would you say
your health is:
Excellent1
Very good2
Good3
Fair4
Poor5
2. Compared to one year ago,
how would your rate your health in general now?
Much better now than one year ago1
Somewhat better now than one year ago2
About the same3
Somewhat worse now than one year ago4
Much worse now than one year ago5

The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

(Circle One Number on Each Line)

Yes, Limited a LotYes, Limited a LittleNo, Not limited at All

3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports

[1][2][3]

4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

[1][2][3]
5. Lifting or carrying groceries[1][2][3]

6. Climbing several flights of stairs

[1][2][3]
7. Climbing one flight of stairs

[1]

[2]

[3]

8. Bending, kneeling, or stooping

[1]

[2]

[3]

9. Walking more than a mile[1][2][3]
10. Walking several blocks[1][2][3]
11. Walking one block[1][2][3]

12. Bathing or dressing yourself

[1]

[2]

[3]

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

(Circle One Number on Each Line)


YesNo

13. Cut down the amount of time you spent on work or other activities

12

14. Accomplished less than you would like

12
15. Were limited in the kind of work or other activities12
16. Had difficulty performing the work or other activities (for example, it took extra effort)12

During the past 4 weeks, 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)?

(Circle One Number on Each Line)


Yes

No

17. Cut down the amount of time you spent on work or other activities

12
18. Accomplished less than you would like12
19. Didn’t do work or other activities as carefully as usual12

20. 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?

(Circle One Number)

Not at all 1

Slightly 2

Moderately 3

Quite a bit 4

Extremely 5

21. How much bodily pain have you had during the past 4 weeks?

(Circle One Number)

None 1

Very mild 2

Mild 3

Moderate 4

Severe 5

Very severe 6

22. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?



(Circle One Number)

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 . . .

(Circle One Number on Each Line)


All of the TimeMost of the TimeA Good Bit of the TimeSome of the TimeA Little of the TimeNone of the Time
23. Did you feel full of pep?123456
24. Have you been a very nervous person?123456
25. Have you felt so down in the dumps that nothing could cheer you up?123456
26. Have you felt calm and peaceful?123456
27. Did you have a lot of energy?123456
28. Have you felt downhearted and blue?123456
29. Did you feel worn out?123456
30. Have you been a happy person?123456
31. Did you feel tired?123456

32. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

(Circle One Number)

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

How TRUE or FALSE is each of the following statements for you.

(Circle One Number on Each Line)


Definitely TrueMostly TrueDon’t KnowMostly FalseDefinitely False
33. I seem to get sick a little easier than other people12345
34. I am as healthy as anybody I know12345
35. I expect my health to get worse12345
36. My health is excellent12345

Share this!