SF-36 QUESTIONNAIRE
April 24th, 2009 - Blog Post in Miscellaneous by Medicalinfo
Name:____________________ Ref. Dr:___________________ Date: _______
ID#: _______________ Age: _______ Gender: M / F
Please answer the 36 questions of the
Health Survey
completely, honestly, and without interruptions.
GENERAL HEALTH:
In general, would you say your health is:
Excellent
Very Good
Good
Fair
Poor
Compared to one year ago, how would you rate your health in general now?
Much better now than one year ago
Somewhat better now than one year ago
About the same
Somewhat worse now than one year ago
Much worse than one year ago
LIMITATIONS OF ACTIVITIES:
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?
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.
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
Yes, Limited a Lot
Yes, Limited a Little
No, Not Limited at all
Lifting or carrying groceries
Yes, Limited a Lot
Yes, Limited a Little
No, Not Limited at all
Climbing several flights of stairs
Yes, Limited a Lot
Yes, Limited a Little
No, Not Limited at all
Climbing one flight of stairs
Yes, Limited a Lot
Yes, Limited a Little
No, Not Limited at all
Bending, kneeling, or stooping
Yes, Limited a Lot
Yes, Limited a Little
No, Not Limited at all
Walking more than a mile
Yes, Limited a Lot
Yes, Limited a Little
No, Not Limited at all
Walking several blocks
Yes, Limited a Lot
Yes, Limited a Little
No, Not Limited at all
Walking one block
Yes, Limited a Lot
Yes, Limited a Little
No, Not Limited at all
Bathing or dressing yourself
Yes, Limited a Lot
Yes, Limited a Little
No, Not Limited at all
PHYSICAL HEALTH PROBLEMS:
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?
Cut down the amount of time you spent on work or other activities
Yes
No
Accomplished less than you would like
Yes
No
Were limited in the kind of work or other activities
Yes
No
Had difficulty performing the work or other activities (for example, it took extra effort)
Yes
No
EMOTIONAL HEALTH PROBLEMS:
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)?
Cut down the amount of time you spent on work or other activities
Yes
No
Accomplished less than you would like
Yes
No
Didn’t do work or other activities as carefully as usual
Yes
No
SOCIAL ACTIVITIES:
Emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?
Not at all
Slightly
Moderately
Severe
Very Severe
PAIN:
How much bodily pain have you had during the past 4 weeks?
None
Very Mild
Mild
Moderate
Severe
Very Severe
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
ENERGY AND EMOTIONS:
These questions are about how you feel and how things have been with you during the last 4 weeks. For each
question, please give the answer that comes closest to the way you have been feeling.
Did you feel full of pep?
All of the time
Most of the time
A good Bit of the Time
Some of the time
A little bit of the time
None of the Time
Have you been a very nervous person?
All of the time
Most of the time
A good Bit of the Time
Some of the time
A little bit of the time
None of the Time
Have you felt so down in the dumps that nothing could cheer you up?
All of the time
Most of the time
A good Bit of the Time
Some of the time
A little bit of the time
None of the Time
Have you felt calm and peaceful?
All of the time
Most of the time
A good Bit of the Time
Some of the time
A little bit of the time
None of the Time
Did you have a lot of energy?
All of the time
Most of the time
A good Bit of the Time
Some of the time
A little bit of the time
None of the Time
Have you felt downhearted and blue?
All of the time
Most of the time
A good Bit of the Time
Some of the time
A little bit of the time
None of the Time
Did you feel worn out?
All of the time
Most of the time
A good Bit of the Time
Some of the time
A little bit of the time
None of the Time
Have you been a happy person?
All of the time
Most of the time
A good Bit of the Time
Some of the time
A little bit of the time
None of the Time
Did you feel tired?
All of the time
Most of the time
A good Bit of the Time
Some of the time
A little bit of the time
None of the Time
SOCIAL ACTIVITIES:
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.)?
All of the time
Most of the time
Some of the time
A little bit of the time
None of the Time
GENERAL HEALTH:
How true or false is each of the following statements for you?
I seem to get sick a little easier than other people
Definitely true
Mostly true
Don’t know
Mostly false
Definitely false
I am as healthy as anybody I know
Definitely true Mostly true Don’t know Mostly false Definitely false
I expect my health to get worse
Definitely true
Mostly true
Don’t know
Mostly false
Definitely false
My health is excellent
Mostly false
Definitely false
