SF-36v1 Standard Sample

3. 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?
Your Health and Well-Being

Yes,
limited
a lot
This survey asks for your views about your health. This information will help
keep track of how you feel and how well you are able to do your usual
activities. Thank you for completing this survey!
For each of the following questions, please mark an
describes your answer.
Excellent
Very good
Good
Poor
2. Compared to one year ago, how would you rate your health in general
now?
Much better
now than one
year ago
Somewhat
better now
than one year
ago
About the
same as one
year ago
.................
.................
Moderate activities, such as moving a

table, pushing a vacuum cleaner,
bowling, or playing golf............................................
.................
.................
Lifting or carrying groceries .....................................
.................
.................
Climbing several flights of stairs ..............................
.................
.................
Climbing one flight of stairs......................................
.................
.................
Bending, kneeling, or stooping..................................
.................
.................
Walking more than a mile .........................................
.................
.................
Walking several blocks .............................................
.................
.................
Walking one block.....................................................
.................
.................
Bathing or dressing yourself......................................
.................
.................
Fair
Somewhat
worse now
than one year
ago
Much worse
now than one
year ago
SF-36 Health Survey 1988, 2002 by Medical Outcomes Trust and QualityMetric Incorporated. All Rights Reserved.
SF-36 is a registered trademark of Medical Outcomes Trust.
(SF-36 Standard, US Version 1.0)
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?
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
Yes
Slightly
Moderately
Quite a bit
Extremely
No
1
No, not
limited
at all
Vigorous activities, such as running, lifting

heavy objects, participating in strenuous
sports .........................................................................
in the one box that best
1. In general, would you say your health is:
Yes,
limited
a little
Cut down on the amount of time you spent

on work or other activities .......................................................
...................
Accomplished less than you would like..................................
...................
7. How much bodily pain have you had during the past 4 weeks?
c
Were limited in the kind of work or other

activities ..................................................................................
...................
Had difficulty performing the work or other

activities (for example, it took extra effort) ............................
...................
None
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 depressed or anxious)?
Yes
a
No
.....................
Accomplished less than you would like................................
.....................
Did work or other activities less carefully

than usual...............................................................................
.....................
1
b
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
Cut down on the amount of time you spent

on work or other activities .....................................................
Very mild
A little bit
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 4 weeks...
All of
the
time
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
time
Most A good Some A little None

of the bit of of the of the of the
time
the
time
time
time
time
Did you feel full of pep?...........................
.......
.......
.......
........
........
Have you been a very nervous

person? ......................................................
.......
.......
.......
........
........
Have you felt so down in the

dumps that nothing could cheer
you up? .....................................................
.......
.......
.......
........
........
Have you felt calm and peaceful?.............
.......
.......
.......
........
........
Did you have a lot of energy? ...................
.......
.......
.......
........
........
.......
.......
.......
........
........
Did you feel worn out? .............................
.......
.......
.......
........
........
Have you been a happy person? ...............
.......
.......
.......
........
........
Did you feel tired?.....................................
.......
.......
.......
........
........
A little of the
time
None of the
time
Definitely
true
Have you felt downhearted

and blue? ...................................................
Some of the
time
11. How TRUE or FALSE is each of the following statements for you?
Most of the
time
Mostly
true
Don't
know
Mostly
false
I seem to get sick a little easier

than other people....................................
...........
...........
...........
...........
I am as healthy as anybody I
know .......................................................
...........
...........
..........
...........
I expect my health to get

worse ......................................................
...........
...........
..........
...........
My health is excellent ............................
...........
...........
..........
...........
Thank you for completing these questions!
Definitely
false

SF-36v1 Standard Sample

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3. The following items are about activities you might do during a typical day.

Your Health and Well-Being

Moderate activities, such as moving a

Lifting or carrying groceries .....................................

Climbing several flights of stairs ..............................

Climbing one flight of stairs......................................

Bending, kneeling, or stooping..................................

Walking more than a mile .........................................

Walking several blocks .............................................

Walking one block.....................................................

Bathing or dressing yourself......................................

Vigorous activities, such as running, lifting

in the one box that best

1. In general, would you say your health is:

Cut down on the amount of time you spent

Accomplished less than you would like..................................

Were limited in the kind of work or other

Had difficulty performing the work or other

Accomplished less than you would like................................

Did work or other activities less carefully

Cut down on the amount of time you spent

Most A good Some A little None

Did you feel full of pep?...........................

Have you been a very nervous

Have you felt so down in the

Have you felt calm and peaceful?.............

Did you have a lot of energy? ...................

Did you feel worn out? .............................

Have you been a happy person? ...............

Did you feel tired?.....................................

Have you felt downhearted

I seem to get sick a little easier

I expect my health to get

My health is excellent ............................

Thank you for completing these questions!

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