12-Item Short Form Survey (SF-12)

Health

Please answer every question by marking one box. If you are unsure about how to answer, please give the best answer you can.

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

Activities

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?

2. 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

3. Climbing several flights of stairs

Yes, limited a lot Yes, limited a little No, Not limited at all

Symptoms

During the past week, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

4. Accomplished less than you would like

5. Were limited in the kind of work or other activites

Psycology

During the past week, 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)?

6. Accomplished less than you would like

7. Didn't do work or other activities as carefully as usual

8. During the past week, how much did pain interfere with your normal work (including both work outside the home and housework)?

Feelings

These questions are about how you feel and how things have been with you during the past week. 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 week -

9. 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

10. 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

11. Have you felt downhearted and blue?

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

12. During the past week, 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 Some of the time A little of the time None of the time