SF-12v2™ Health Survey Scoring Demonstration


This survey asks for your views about your health. This information will help 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.


1.

In general, would you say your health is:

Excellent

Very good

Good

Fair

Poor


2.

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

a

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

b

Climbing several flights of stairs


3.

During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

All
of the time

Most
of the time

Some
of the time

A little
of the time

None
of the time

a

Accomplished less than you would like

b

Were limited in the kind of work or other activities


4.

During the past 4 weeks, how much of the time 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)?

All
of the time

Most
of the time

Some
of the time

A little
of the time

None
of the time

a

Accomplished less than you would like

b

Did work or activities less carefully than usual


5.

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


6.

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

Some
of the time

A little
of the time

None
of the time

a

Have you felt calm and peaceful?

b

Did you have a lot of energy?

c

Have you felt downhearted and depressed?


7.

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!