Short-Form 36-Item Health Survey (SF-36) Medical Outcomes Study Questionnaire Short Form 36 Health Survey 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 circle the number that best describes your answer. 1. In general, would you say your health is: Excellent 1 Very good 2 Good 3 Fair 4 Poor 5 2. Compared to one year ago, Much better now than one year ago 1 Somewhat better now than one year ago 2 About the same 3 Somewhat worse now than one year ago 4 Much worse now than one year ago 5 3. 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? (Circle One Number on Each Line) a. Vigorous activities, such as running, lifting heavy object,participating in strenuous sports b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf c. Lifting or carrying groceries d. Climbing several fights of stairs e. Climbing one fight of stairs f. Bending, kneeling, or stooping g. Walking more than a mile h. Walking several blocks i. Walking one block j. Bathing or dressing yourself Yes, Limited Yes, Limited a No, Not limited a lot little at All (1) (2) (3) 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 37
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