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SF-36QUESTIONNAIREName:____________________Ref.Dr:___________________Date:_______ID#:_______________Age:_______Gender:M/FPleaseanswerthe36questionsoftheHealthSurveycompletely,honestly,andwithoutinterruptions.GENERALHEALTH:Ingeneral,wouldyousayyourhealthis:ExcellentVeryGoodGoodFairPoorComparedtooneyearago,howwouldyourateyourhealthingeneralnow?MuchbetternowthanoneyearagoSomewhatbetternowthanoneyearagoAboutthesameSomewhatworsenowthanoneyearagoMuchworsethanoneyearagoLIMITATIONSOFACTIVITIES:Thefollowingitemsareaboutactivitiesyoumightdoduringatypicalday.Doesyourhealthnowlimityouintheseactivities?Ifso,howmuch?Vigorousactivities,suchasrunning,liftingheavyobjects,participatinginstrenuoussports.Yes,LimitedalotYes,LimitedaLittleNo,NotLimitedatallModerateactivities,suchasmovingatable,pushingavacuumcleaner,bowling,orplayinggolfYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallLiftingorcarryinggroceriesYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallClimbingseveralflightsofstairsYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallClimbingoneflightofstairsYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallBending,kneeling,orstoopingYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallWalkingmorethanamileYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallWalkingseveralblocksYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallWalkingoneblockYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallBathingordressingyourselfYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallPHYSICALHEALTHPROBLEMS:Duringthepast4weeks,haveyouhadanyofthefollowingproblemswithyourworkorotherregulardailyactivitiesasaresultofyourphysicalhealth?CutdowntheamountoftimeyouspentonworkorotheractivitiesYesNoAccomplishedlessthanyouwouldlikeYesNoWerelimitedinthekindofworkorotheractivitiesYesNoHaddifficultyperformingtheworkorotheractivities(forexample,ittookextraeffort)YesNoEMOTIONALHEALTHPROBLEMS:Duringthepast4weeks,haveyouhadanyofthefollowingproblemswithyourworkorotherregulardailyactivitiesasaresultofanyemotionalproblems(suchasfeelingdepressedoranxious)?CutdowntheamountoftimeyouspentonworkorotheractivitiesYesNoAccomplishedlessthanyouwouldlikeYesNoDidn'tdoworkorotheractivitiesascarefullyasusualYesNoSOCIALACTIVITIES:Emotionalproblemsinterferedwithyournormalsocialactivitieswithfamily,friends,neighbors,orgroups?NotatallSlightlyModeratelySevereVerySeverePAIN:Howmuchbodilypainhaveyouhadduringthepast4weeks?NoneVeryMildMildModerateSevereVerySevereDuringthepast4weeks,howmuchdidpaininterferewithyournormalwork(includingbothworkoutsidethehomeandhousework)?NotatallAlittlebitModeratelyQuiteabitExtremelyENERGYANDEMOTIONS:Thesequestionsareabouthowyoufeelandhowthingshavebeenwithyouduringthelast4weeks.Foreachquestion,pleasegivetheanswerthatcomesclosesttothewayyouhavebeenfeeling.Didyoufeelfullofpep?AllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoubeenaverynervousperson?AllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoufeltsodowninthedumpsthatnothingcouldcheeryouup?AllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoufeltcalmandpeaceful?AllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeDidyouhavealotofenergy?AllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoufeltdownheartedandblue?AllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeDidyoufeelwornout?AllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoubeenahappyperson?AllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeDidyoufeeltired?AllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeSOCIALACTIVITIES:Duringthepast4weeks,howmuchofthetimehasyourphysicalhealthoremotionalproblemsinterferedwithyoursocialactivities(likevisitingwithfriends,relatives,etc.)?AllofthetimeMostofthetimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeGENERALHEALTH:Howtrueorfalseiseachofthefollowingstatementsforyou?IseemtogetsickalittleeasierthanotherpeopleDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalseIamashealthyasanybodyIknowDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalseIexpectmyhealthtogetworseDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalseMyhealthisexcellentDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalse