No Mild Negative Results
No Dangerous Negative Results
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
3. Climbing several flights of stairs
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
10. Did you have a lot of energy?
11. Have you felt downhearted and blue?
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.)?