SF-12 Health Survey Scoring Demonstration

Your Health and Well-Being

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. Thank you for completing this survey!

For each of the following questions, please select the one response that best describes your 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 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, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

		Yes	No
a.	Accomplished less than you would like
b.	Were limited in the kind of work or other activities

4. 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)?

		Yes	No
a.	Accomplished less than you would like
b.	Did work or other 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	A good bit 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 blue?

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