In general, would you say your health is: Excellent Very Good Good Fair Poor
The Following Two Questions Are About Activities You Might Do During A Typical Day. Does YOUR HEALTH NOW LIMIT YOU In These Activities? If So, How Much?
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
Climbing SEVERAL flights of stairs: Yes, Limited A Lot Yes, Limited A Little No, Not Limited At All
During The PAST 4 WEEKS Have You Had Any Of The Following Problems With Your Work Or Other Regular Activities AS A RESULT OF YOUR PHYSICAL HEALTH?
ACCOMPLISHED LESS than you would like: Yes No
Were limited in the KIND of work or other activities: Yes No
During The PAST 4 WEEKS, Were You Limited In The Kind Of Work You Do Or Other Regular Activities AS A RESULT OF ANY EMOTIONAL PROBLEMS (Such As Feeling Depressed Or Anxious)?
ACCOMPLISHED LESS than you would like: Yes No
Didn’t do work or other activities as CAREFULLY as usual: Yes No
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
The Next Three Questions Are About How You Feel And How Things Have Been 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 €“
Have you felt calm and peaceful? All of the Time Most of the Time A Good Bit of the Time Some of the Time A Little of the Time None of the Time
Did you have a lot of energy? All of the Time Most of the Time A Good Bit of the Time Some of the Time A Little of the Time None of the Time
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.)?
All of the Time Most of the Time A Good Bit of the Time Some of the Time A Little of the Time None of the Time
