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During the past 4 weeks, how much did pain interfere with your normal work (including both work outside home and housework)?
(Please tick one.)
Not at all______
A little bit______
Moderately_____
Quite a bit_____
Extremely______
These questions are about how you feel and how things have been with you during the past 4 weeks. Please give the one answer
that is closest to the way you have been feeling for each item.
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(Please circle one number on each line.)
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All of the time
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Most of the time
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A good bit of the time
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Some of the time
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A little of the time
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None of the time
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9(a) Did you feel full of life?
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1
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2
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3
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4
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5
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6
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9(b) Have you been a very nervous person?
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1
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2
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3
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4
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5
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6
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9(c) Have you felt so down in the dumps that nothing could cheer you up?
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1
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2
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3
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4
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5
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6
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9(d) Have you felt calm and peaceful?
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1
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2
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3
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4
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5
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6
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9(e) Did you have a lot of energy?
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1
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2
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3
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4
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5
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6
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9(f) Have you felt downhearted and blue?
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1
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2
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3
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4
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5
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6
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9(g) Did you feel worn out?
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1
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2
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3
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4
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5
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6
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9(h) Have you been a happy person?
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1
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2
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3
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4
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5
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6
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9(i) Did you feel tired?
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1
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2
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3
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4
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5
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6
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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 with friends, relatives etc.) (Please tick one.)
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 statement for you?
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(Please circle one number on each line.)
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Definitely true
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Mostly true
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Don't know
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Mostly false
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Definitely false
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11(a) I seem to get sick a little easier than other people
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1
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2
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3
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4
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5
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11(b) I am as healthy as anybody I know
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1
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2
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3
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4
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5
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11(c) I expect my health to get worse
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1
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2
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3
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4
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5
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11(d) My health is excellent
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1
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2
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3
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4
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5
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12) What year was your cancer diagnosed?
______________
13) How old are you?
______________
14) Are you male or female? (Please tick one.)
Male__________
Female________
Thank you for taking your time and completing this survey!
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