|
1) In general, would you say your health is : (Please tick one)
Excellent ______
Very Good _____
Good _________
Fair __________
Poor __________
2) Compared to one year ago, how would you rate your health in general now? (Please tick one.)
Much better than one year ago ___________
Somewhat better 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? (Please circle one number on each line.)
|
Activities
|
Yes, Limited A Lot
|
Yes, Limited A Little
|
Not Limited At All
|
|
3(a) Vigorous activities such as running, lifting heavy objects, participating in strenuous sports
|
1
|
2
|
3
|
|
3(b) Moderate activities such as moving a table, pushing a vacuum cleaner, bowling or playing golf
|
1
|
2
|
3
|
|
3(c) Lifting or carrying groceries
|
1
|
2
|
3
|
|
3(d) Climbing several flights of stairs
|
1
|
2
|
3
|
|
3(e) Climbing one flight of stairs
|
1
|
2
|
3
|
|
3(f) Bending, kneeling or stooping
|
1
|
2
|
3
|
|
3(g) Walking more than a mile
|
1
|
2
|
3
|
|
3(h) Walking several blocks
|
1
|
2
|
3
|
|
3(i) Walking one block
|
1
|
2
|
3
|
|
3(j) Bathing or dressing yourself
|
1
|
2
|
3
|
|
3(k) Running/jogging more than a mile
|
1
|
2
|
3
|
|
3(l) Running/jogging several blocks
|
1
|
2
|
3
|
|
3(m) Running/jogging one block
|
1
|
2
|
3
|
|
3(n) Shopping in a store
|
1
|
2
|
3
|
|
3(o) Boating, Canoeing, Power Boating, Sailing
|
1
|
2
|
3
|
|
3(p) Swimming
|
1
|
2
|
3
|
|
3(q) Excercising
|
1
|
2
|
3
|
|
3(r) Cleaning the house
|
1
|
2
|
3
|
|
3(s) Cooking
|
1
|
2
|
3
|
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?
|
(Please circle one number on each line.)
|
Yes
|
No
|
|
4(a) Cut down the amount of time you spent on work or other activities
|
1
|
2
|
|
4(b) Accomplished less than you like
|
1
|
2
|
|
4(c) Were limited in the kind of work or other activities
|
1
|
2
|
|
4(d) Had difficulty performing the work or other activites (for example, it took extra effort)
|
1
|
2
|
|
|
5) During the last 4 weeks, have you had any of the following problems with your tork or other regular daily activites as
a result of any emotional problems (e.g. feeling depressed or anxious)
|
(Please circle one number on each line.)
|
Yes
|
No
|
|
|
5(a) Cut down on the amount you spent on work or other activites
|
1
|
2
|
|
|
5(b) Accomplished less than you like
|
1
|
2
|
|
|
5(c) Didn't do work or other activities as carefully as usual
|
1
|
2
|
|
6) During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social
activities woth family, friends, neighbors, or groups? (Please tick one.)
Not at all_____
Slightly_______
Moderately____
Quite a bit____
Extremely_____
|
