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:
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?
No, not limitedat 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?
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)?
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
Quite a bit
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...
Allof the time
Mostof the time
A goodbit ofthe time
Someof the time
A littleof the time
Noneof 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 thetime
Most of thetime
Some of thetime
A little of thetime
None of thetime
Thank you for completing these questions!