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36-Item Short Form Survey Instrument (SF-36)

Date Of Birth
Day
Month
Year

Choose one option for each questionnaire item.

1. In general, would you say your health is:
1 - Excellent
2 - Very good
3 - Good
4 - Fair
5 - Poor
2. Compared to one year ago, how would you rate your health in general now?
1 - Much better now than one year ago
2 - Somewhat better now than one year ago
3 - About the same
4 - Somewhat worse now than one year ago
5 - Much worse now than one year ago

The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
5. Lifting or carrying groceries
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
6. Climbing several flights of stairs
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
7. Climbing one flight of stairs
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
8. Bending, kneeling, or stooping
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
9. Walking more than a mile
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
10. Walking several blocks
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
11. Walking one block
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
12. Bathing or dressing yourself
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all

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?

13. Cut down the amount of time you spent on work or other activities
1 - Yes
2 - No
14. Accomplished less than you would like
1 - Yes
2 - No
15. Were limited in the kind of work or other activities
1 - Yes
2 - No
16. Had difficulty performing the work or other activities (for example, it took extra effort)
1 - Yes
2 - No

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)?

17. Cut down the amount of time you spent on work or other activities
1 - Yes
2 - No
18. Accomplished less than you would like
1 - Yes
2 - No
19. Didn't do work or other activities as carefully as usual
1 - Yes
2 - No
20. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?
1 - Not at all
2 - Slightly
3 - Moderately
4 - Quite a bit
5 - Extremely
21. How much bodily pain have you had during the past 4 weeks?
1 - None
2 - Very mild
3 - Mild
4 - Moderate
5 - Severe
6 - Very severe
22. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
1 - Not at all
2 - A little bit
3 - Moderately
4 - Quite a bit
5 - 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...

23. Did you feel full of pep?
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
24. Have you been a very nervous person?
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
25. Have you felt so down in the dumps that nothing could cheer you up?
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
26. Have you felt calm and peaceful?
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
27. Did you have a lot of energy?
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
28. Have you felt downhearted and blue?
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
29. Did you feel worn out?
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
30. Have you been a happy person?
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
31. Did you feel tired?
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
32. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
1 - All of the time
2 - Most of the time
3 - Some of the time
4 - A little of the time
5 - None of the time

How TRUE or FALSE is each of the following statements for you.

33. I seem to get sick a little easier than other people
1 - Definitely true
2 - Mostly true
3 - Don't know
4 - Mostly false
5 - Definitely false
34. I am as healthy as anybody I know
1 - Definitely true
2 - Mostly true
3 - Don't know
4 - Mostly false
5 - Definitely false
35. I expect my health to get worse
1 - Definitely true
2 - Mostly true
3 - Don't know
4 - Mostly false
5 - Definitely false
36. My health is excellent
1 - Definitely true
2 - Mostly true
3 - Don't know
4 - Mostly false
5 - Definitely false
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