The
SF-36TM Health
Survey
STUDY
#
Instructions
for Completing the Questionnaire
Please
answer every question. Some
questions may look like others, but each
one
is different. Please take the time
to read and answer each question
carefully
by filling in the bubble that best represents your
response.
EXAMPLE
This is
for your review. Do not answer this question. The questionnaire
begins with
this section. Your Health in General
below.
For each
question you will be asked to fill in a bubble in each
line:
1.
How
strongly do you agree or disagree with each of the following
statements?
Strongly
Agree Uncertain Disagree
Strongly
agree
disagree
a)
I
enjoy listening to music.
magazines.
Please
begin answering the questions now.
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
Somewhat better
About the Somewhat
Much worse
now than
one
now than one
same as one worse now than now than
one
year ago
year ago
year ago one year ago
year
ago
Please
turn the page and continue
3.
The
following items are about activities you might do during a typical day. Does your
Yes,
Yes,
No, not
limited limited limited
a lot
a
little
at all
health now limit
you in
these activities? If so, how much?
a)
Vigorous
activities, such
as running, lifting heavy
objects,
participating in strenuous sports
b)
Moderate
activities, such
as moving a table, pushing a
vacuum
cleaner, bowling, or playing golf
c)
Lifting
or carrying groceries
d)
Climbing
several flights of stairs
e)
Climbing
one flight of stairs
f)
Bending,
kneeling, or stooping
j)
Bathing
or dressing yourself
4.
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?
Yes No
a) Cut down on the amount of time
you spent on
work
or other activities
b) Accomplished less than you
would like
c)
Were
limited in the kind of work or other
activities
d) Had difficulty performing
the work or other
activities
(for example, it took extra time)
5.
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
Yes
No
depressed
or anxious)?
a) Cut down on the amount of time
you spent on
work
or other activities
b) Accomplished less than you
would like
c)
Didn’t
do work or other activities as carefully as
usual
Please
turn the page and continue
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
Slightly
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
four weeks….
All of
Most of A good Some
A little
None the
the
bit
of
of
the of
the
of the time
time
the time time time
time
b)
have
you been a very nervous
person?
c)
have
you felt so down in the dumps
nothing
could cheer you up?
d)
have
you felt calm and peaceful?
e) did you
have a lot of energy?
f)
have
you felt downhearted and blue?
h)
have
you been a happy person?
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
Most of the
Some of the
None of the
time
time
time
time
11.
How
TRUE or FALSE is each of the following statements for you?
Definitely
Mostly Don’t
Mostly
Definitely true
true
know false
false
a) I seem to get
sick a little easier than
other people
b)
I am as healthy as anybody I
know
c) I expect my
health to get worse
THANK YOU
FOR COMPLETEING THIS QUESTIONNAIRE!