SF-12 v2 Health and Well-Being

For each of the following questions, please circle or X the best possible answer.

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 Yes, Limited No, Not

A Lot A little Limited At All

·Moderate activities, such as moving a table,

pushing a vacuum cleaner, bowling, or playing golf . . . .  

·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 of other regular daily activities as a result of your physical health?

All of Most of Some of A little of None of

the time the time the time the time the time

·Accomplished less then you would like . . . . . . .     

·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 Most of Some of A little of None of

the time the time the time the time the time

·Accomplished less then you would like . . . . . . .     

·Were limited in the kind of work or other activities     

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 Most of Some of A little of None of

the time the time the time the time the time

·Have you felt calm and peaceful?. . . . . . . . . .     

·Did you have a lot of energy? . . . . . . . . . . . . . .    

·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 Most of Some of A little of None of

the time the time the time the time the time