Questions | Not at all | A little | Quite a bit | Very much |
---|---|---|---|---|
1. Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase? | 1 | 2 | 3 | 4 |
2. Do you have any trouble taking a long walk? | 1 | 2 | 3 | 4 |
3. Do you have any trouble taking a short walk outside of the house? | 1 | 2 | 3 | 4 |
4. Do you need to stay in bed or a chair during the day? | 1 | 2 | 3 | 4 |
5. Do you need help with eating, dressing, washing yourself, or using the toilet? | 1 | 2 | 3 | 4 |
During the past week: | Â | Â | Â | Â |
6. Were you limited in doing either your work or other daily activities? | 1 | 2 | 3 | 4 |
7. Were you limited in pursuing your hobbies or other leisure time activities? | 1 | 2 | 3 | 4 |
8. Were you short of breath? | 1 | 2 | 3 | 4 |
9. Have you had pain? | 1 | 2 | 3 | 4 |
10. Did you need to rest? | 1 | 2 | 3 | 4 |
11. Have you had trouble sleeping? | 1 | 2 | 3 | 4 |
12. Have you felt weak? | 1 | 2 | 3 | 4 |
13. Have you lacked appetite? | 1 | 2 | 3 | 4 |
14. Have you felt nauseated? | 1 | 2 | 3 | 4 |
15. Have you vomited? | 1 | 2 | 3 | 4 |
16. Have you been constipated? | 1 | 2 | 3 | 4 |
During the past week: | Â | Â | Â | Â |
17. Have you had diarrhea? | 1 | 2 | 3 | 4 |
18. Were you tired? | 1 | 2 | 3 | 4 |
19. Did pain interfere with your daily activities? | 1 | 2 | 3 | 4 |
20. Have you had difficulty in concentrating on things, like reading a newspaper or watching television? | 1 | 2 | 3 | 4 |
21. Did you feel tense? | 1 | 2 | 3 | 4 |
22. Did you worry? | 1 | 2 | 3 | 4 |
23. Did you feel irritable? | 1 | 2 | 3 | 4 |
24. Did you feel depressed? | 1 | 2 | 3 | 4 |
25. Have you had difficulty remembering things? | 1 | 2 | 3 | 4 |
26. Has your physical condition or medical treatment interfered with your family life? | 1 | 2 | 3 | 4 |
27. Has your physical condition or medical treatment interfered with your social activities? | 1 | 2 | 3 | 4 |
28. Has your physical condition or medical treatment caused you financial difficulties? | 1 | 2 | 3 | 4 |
For the following questions please circle the number between 1 and 7 that best applies to you. | ||||
29. How would you rate your overall health during the past week? | ||||
        1      2      3      4      5      6      7 | ||||
Very poor                        Excellent | ||||
30. How would you rate your overall quality of life during the past week? | ||||
        1      2      3      4      5      6      7 | ||||
Very poor                          Excellent |