Health Survey

Choose one option for each questionnaire item.

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* 1. First name

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* 2. Last name

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* 3. In general, would you say your health is:

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* 4. Compared to one year ago, how would you rate your health in general now?

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* 5. 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?

  Yes, limited a lot Yes, limited a little No, not limited at all
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
Lifting or carrying groceries
Climbing several flights of stairs
Climbing one flight of stairs
Bending, kneeling, or stooping
Walking more than a mile
Walking several blocks
Walking one block
Bathing or dressing yourself

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* 6. 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
Cut down the amount of time you spent on work or other activities
Accomplished less than you would like
Were limited in the kind of work or other activities
Had difficulty performing the work or other activities (for example, it took extra effort)

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* 7. 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
Cut down the amount of time you spent on work or other activities
Accomplished less than you would like
Didn't do work or other activities as carefully as usual

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* 8. 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?

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* 9. How much bodily pain have you had during the past 4 weeks?

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* 10. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

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* 11. 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
Did you feel full of pep?
Have you been a very nervous person?
Have you felt so down in the dumps that nothing could cheer you up?
Have you felt calm and peaceful?
Did you have a lot of energy?
Have you felt downhearted and blue?
Did you feel worn out?
Have you been a happy person?
Did you feel tired?

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* 12. 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.)?

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

  Definitely true Mostly true Don't know Mostly false Definitely false
I seem to get sick a little easier than other people
I am as healthy as anybody I know
I expect my health to get worse
My health is excellent

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Survey questions provided by Rand Health.

Survey questions provided by <a href="https://www.rand.org/health.html" rel="nofollow" target="_blank">Rand Health</a>.

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