SF-12® Health Survey Scoring Demonstration

SF-12® Health Survey Scoring Demonstration

This survey asks for your views about your health. This information will help you keep track of how you feel and how well you are able to do your usual activities. Answer every question by selecting the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can.

In general, would you say your health is:

	Excellent	Very good	Good	Fair	Poor

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?

Yes,
limited
a lot

Yes,
limited
a little

No, not limited
at all

Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

Climbing several flights of stairs

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?

Yes

Accomplished less than you would like

Were limited in the kind of work or other activities

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

Accomplished less than you would like

Did work or other activities less carefully than usual

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	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. 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

Most
of the time

A good
bit of
the time

Some
of the time

A little
of the time

None
of the time

Have you felt calm and peaceful?

Did you have a lot of energy?

Have you felt downhearted and blue?

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 of the time	Some of the time	A little of the time	None of the time

Thank you for completing these questions!