SF-36健康量表文卷

Name:____________________ID#: _______________

Ref. Dr:___________________

Age: _______

Date: _______

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: ExcellentVery Good

GoodFairPoor

Compared to one year ago, how would you rate your health in general now? Much better now than one year agoSomewhat better now than one year agoAbout the same

Somewhat worse now than one year agoMuch 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 theseactivities? If so, how much?

Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.Yes, Limited a lotYes, Limited a LittleNo, Not Limited at allModerate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golfYes, Limited a LotYes, Limited a LittleNo, Not Limited at allLifting or carrying groceriesYes, Limited a LotClimbing several flights of stairsYes, Limited a LotClimbing one flight of stairsYes, Limited a LotBending, kneeling, or stoopingYes, Limited a LotWalking more than a mileYes, Limited a LotWalking several blocksYes, Limited a LotWalking one blockYes, Limited a Lot

Yes, Limited a LittleNo, Not Limited at all

Yes, Limited a LittleNo, Not Limited at all

Yes, Limited a LittleNo, Not Limited at all

Yes, Limited a LittleNo, Not Limited at all

Yes, Limited a LittleNo, Not Limited at all

Yes, Limited a LittleNo, Not Limited at all

Yes, Limited a LittleNo, Not Limited at all

Bathing or dressing yourselfYes, Limited a Lot

Yes, Limited a LittleNo, 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 asa result of your physical health?

Cut down the amount of time you spent on work or other activitiesYesNoAccomplished less than you would likeYesNo

Were limited in the kind of work or other activitiesYesNo

Had difficulty performing the work or other activities (for example, it took extra effort)YesNo

EMOTIONAL HEALTH PROBLEMS:

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities asa result of any emotional problems (such as feeling depressed or anxious)? Cut down the amount of time you spent on work or other activitiesYesNoAccomplished less than you would likeYesNo

Didn't do work or other activities as carefully as usualYesNo

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 thehome 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 eachquestion, please give the answer that comes closest to the way you have been feeling. Did you feel full of pep?All of the timeMost of the time

A good Bit of the TimeSome of the timeA little bit of the timeNone of the Time

Have you been a very nervous person?All of the timeMost of the time

A good Bit of the TimeSome of the timeA little bit of the timeNone of the Time

Have you felt so down in the dumps that nothing could cheer you up?All of the timeMost of the time

A good Bit of the TimeSome of the timeA little bit of the timeNone of the TimeHave you felt calm and peaceful?All of the timeMost of the time

A good Bit of the TimeSome of the timeA little bit of the timeNone of the TimeDid you have a lot of energy?All of the timeMost of the time

A good Bit of the TimeSome of the timeA little bit of the time None of the Time

Have you felt downhearted and blue?All of the timeMost of the time

A good Bit of the TimeSome of the timeA little bit of the timeNone of the TimeDid you feel worn out?All of the timeMost of the time

A good Bit of the TimeSome of the timeA little bit of the timeNone of the Time

Have you been a happy person?All of the timeMost of the time

A good Bit of the TimeSome of the timeA little bit of the timeNone of the TimeDid you feel tired?All of the timeMost of the time

A good Bit of the TimeSome of the timeA little bit of the timeNone of the Time

SOCIAL ACTIVITIES:

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered withyour social activities (like visiting with friends, relatives, etc.)?All of the timeMost of the timeSome of the timeA little bit of the timeNone 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 peopleDefinitely trueMostly trueDon't knowI am as healthy as anybody I knowDefinitely trueMostly trueI expect my health to get worseDefinitely trueMostly trueMy health is excellentDefinitely true

Mostly falseDefinitely false

Don't knowMostly falseDefinitely false

Don't knowMostly falseDefinitely false

Mostly trueDon't knowMostly falseDefinitely false