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1. In general would you say your health is:
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2. Compared to one year ago, how would you rate your health in general now?
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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? Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
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4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
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5. Lifting or carrying groceries
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6. Climbing several flights of stairs
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7. Climbing one flight of stairs
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8. Bending, kneeling, or stooping
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9. Walking more than a mile
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10. Walking several blocks
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11. Walking one block
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12. Bathing or dressing yourself
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13. During the past four weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? Cut down the amount of time you spent on work or other activities
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14. Accomplished less than you would like?
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15. Were limited in the kind of work or other activities
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16. Had difficulty performing the work or other activities (for example, it took extra effort)
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17. 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 emotional problems (such as feeling depressed or anxious)? Cut down on the amount of time you spent on work or other activities:
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18. Accomplished less than you would like
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19. Didn't do work or other activities as carefully as usual
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20. During the past 4 weeks, to what extent has your physical health of emotional problems interfered with you normal social activites with family, friends, neighbors, or groups?
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21. How much bodily pain have you had during the past 4 weeks?
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22. During the past 4 weeks, how much did pain interfer with your normal work (including both work outside the home and housework)?
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23. 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 clostest to the way you have been feeling. How much of the time did you feel full of pep?
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24. How much of the time during the past 4 weeks have you been a very nervous person?
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25. How much of the time during the past 4 weeks have you felt so down in the dumps that nothing could cheer you up?
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26. How much of the time during the past 4 weeks have you felt calm and peaceful?
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27. How much of the time during the past 4 weeks did you have a lot of energy?
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28. How much of the time during the past 4 weeks have you felt downhearted and blue?
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29. How much of the time during the past 4 weeks did you feel worn out?
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30. How much of the time during the past 4 weeks have you been a happy person?
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31. How much of the time during the past 4 weeks did you feel tired?
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32. 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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33. How true or false is each of the following statements for you? I seem to get sick a little easier than other people
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34. I am as healthy as anybody I know
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35. I expect my health to get worse
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36. My health is excellent
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