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Demographics Your Name: Your Email Address: Health Survey 1. In general, would you say your health is: ExcellentVery goodGoodFairPoor 2. 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 sameSomewhat worse now than one year agoMuch worse now than one year ago 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? 3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports Yes, limited a lotYes, limited a littleNo, not limited at all 4. Moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Yes, limited a lotYes, limited a littleNo, not limited at all 5. Lifting or carrying groceries Yes, limited a lotYes, limited a littleNo, not limited at all 6. Climbing several flight of stairs Yes, limited a lotYes, limited a littleNo, not limited at all 7. Climbing one flight of stairs Yes, limited a lotYes, limited a littleNo, not limited at all 8. Bending, kneeling, or stooping Yes, limited a lotYes, limited a littleNo, not limited at all 9. Walking more than a mile Yes, limited a lotYes, limited a littleNo, not limited at all 10. Walking several blocks Yes, limited a lotYes, limited a littleNo, not limited at all 11. Walking one block Yes, limited a lotYes, limited a littleNo, not limited at all 12. Bathing or dressing yourself Yes, limited a lotYes, limited a littleNo, not limited at all 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? 13. Had to decrease the amount of time you spent on work or other activities YesNo 14. Accomplished less than you would haved liked YesNo 15. Were limited in the kind of work or other activities YesNo 16. Had difficulty performing your work or other activities (for example, it took extra effort) YesNo 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)? 17. Had to decrease the amount of time you spent on work or other activities YesNo 18. Accomplished less than you would have liked YesNo 19. Participated in other activities less carefully than usual YesNo 20. 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? Not at allSlightlyModeratelyQuite a bitExtremely 21. How much bodily pain have you had during the past 4 weeks NoneVery mildMildModerateSevereVery Severe 22. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? Not at allA little bitModeratelyQuite a bitExtremely These questions are about how you have felt in the past 4 weeks. For each question, please give the one answer that describes your feelings: 23. Did you feel full of pep? All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time 24. Have you been a very nervous person? All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time 25. Have you felt so down in the dumps that nothing could cheer you up? All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time 26. Have you felt calm and peaceful? All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time 27. Did you have a lot of energy? All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time 28. Have you felt downhearted and blue? All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time 29. Did you feel worn out? All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time 30. Have you been a happy person? All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time 31. Did you feel tired? All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time 32. During the past 4 weeks, how much of the time has your physicial health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? All of the timeMost of the timeSome of the timeA little of the timeNone of the time Please answer TRUE or FALSE for each of the following statements: 33. I seem to get sick a little easier than other people Definitely TrueMostly TrueDon't KnowMostly FalseDefinitely False 34. I am as healthy as anybody I know Definitely TrueMostly TrueDon't KnowMostly FalseDefinitely False 35. I expect my health to get worse Definitely TrueMostly TrueDon't KnowMostly FalseDefinitely False 36. My health is excellent Definitely TrueMostly TrueDon't KnowMostly FalseDefinitely False Complete the survey. Cancel.