Version May 2024
| The following questions ask for your views about your health - how you feel and how well you are able to do your usual activities. All kinds of people across the country are being asked these same questions. Their answers and yours will help to improve health care for everyone. There are no right or wrong answers; please choose the answer that best fits your life right now. |
| Answer each question by marking an "X" next to the best response. For example: |
| What is your gender? |
| ___ Male |
| _X_ Female |
| Q1. In general, would you say your health is: |
| ___ Excellent |
| ___ Very good |
| ___ Fair |
| ___ Poor |
| Q2. 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? |
| a. 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 |
| b. Climbing several flights of stairs? |
| ___ Yes, limited a lot |
| ___ Yes, limited a little |
| ___ No, not limited at all |
| Q3. During the past four weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? |
| a. Accomplished less than you would like |
| ___ No, none of time |
| ___ Yes, a little of the time |
| ___ Yes, some of the time |
| ___ Yes, most of the time |
| ___ Yes, all of the time |
| b. Were limited in the kind of work or other activities |
| ___ No, none of the time |
| ___ Yes, a little of the time |
| ___ Yes, some of the time |
| ___ Yes, most of the time |
| ___ Yes, all of the time |
| Q4. During the past four 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)? |
| a. Accomplished less than you would like |
| ___ No, none of the time |
| ___ Yes, a little of the time |
| ___ Yes, some of the time |
| ___ Yes, most of the time |
| ___ Yes, all of the time |
| b. Didn't do work or other activities as carefully as usual |
| ___ No, none of the time |
| ___ Yes, a little of the time |
| ___ Yes, some of the time |
| ___ Yes, most of the time |
| ___ Yes, all of the time |
| Q5. During the past four weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? |
| ___ 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 four weeks. For each question, please give the one answer that comes closest to the way you have been feeling. |
| Q6a. How much of the time during the past four weeks: |
| 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 |
| Q6b. How much of the time during the past four weeks: |
| 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 |
| Q6c. How much of the time during the past four weeks: |
| 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 |
| Q7. During the past four weeks, 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 |
| Now, we'd like to ask you some questions about how your health may have changed |
| Q8. Compared with one year ago, how would you rate your physical health in general now? |
| ___ Much better |
| ___ Slightly better |
| ___ About the same |
| ___ Slightly worse |
| ___ Much worse |
| Q8. Compared with one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) now? |
| ___ Much better |
| ___ Slightly better |
| ___ About the same |
| ___ Slightly worse |
| ___ Much worse |
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