SF-12 Health Survey
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Subject ID *
Initials *
Visit Number *
Directions: Please answer every question to the best of your ability. Some questions may look like others, but each one is different. Please take the time to read and answer each question carefully by filling in the bubble that best represents your response.
1. In general, would you say your health is: *
1 = Excellent
2 = Very Good
3 = Good
4 = Fair
5 = Poor
I do not wish to answer this question.
2. 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? *
1 = Limited a lot
2 = Limited a little
3 = No, not limited
I do not wish to answer this question.
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?
b. Climbing several flights of stairs?
3. During the last 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? *
1 = Yes
2 = No
I do not wish to answer this question.
a. Accomplished less than you would like.
b. Were limited in the kind of work or other activities.
4. 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)? *
1 = Yes
2 = No
I do not wish to answer this question.
a. Accomplished less than you would like.
b. Didn't do work or other activities as carefully as usual.
5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home, and housework)? *
1 = Not at all
2 = A little bit
3 = Moderately
4 = Quite a bit
5 = Extremely
I do not wish to answer this question.
6. 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.... *
1 = All of the time
2 = Most of the time
3 = A good bit of the time
4 = Some of the time
5 = A little of the time
6 = None of the time
I do not wish to answer this question.
a. Have you felt calm and peaceful?
b. Did you have a lot of energy?
c. Have you felt downhearted and blue?
7. 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.)? *
1 = All of the time
2 = Most of the time
3 = A good bit of the time
4 = Some of the time
5 = A little of the time
6 = None of the time
I do not wish to answer this question.
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