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SF-12 Health Survey: Moderate Activities Such As Moving A Table, Pushing

This survey asks individuals to rate their overall health and the extent to which their physical or emotional health impacts daily activities and social interactions. It contains 12 questions regarding general health status, limitations in moderate activities and climbing stairs due to health, accomplishing less than desired or being limited in work/activities due to physical or emotional problems, pain interference, feelings of calmness and energy, and interference of health issues with social life. The responses are used to track an individual's health and well-being over time.

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yoyo73
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191 views1 page

SF-12 Health Survey: Moderate Activities Such As Moving A Table, Pushing

This survey asks individuals to rate their overall health and the extent to which their physical or emotional health impacts daily activities and social interactions. It contains 12 questions regarding general health status, limitations in moderate activities and climbing stairs due to health, accomplishing less than desired or being limited in work/activities due to physical or emotional problems, pain interference, feelings of calmness and energy, and interference of health issues with social life. The responses are used to track an individual's health and well-being over time.

Uploaded by

yoyo73
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

SF-12 Health Survey

This survey asks for your views about your health. This information will help keep track of how you feel and how
well you are able to do your usual activities. Answer each question by choosing just one answer. If you are
unsure how to answer a question, please give the best answer you can.

1. In general, would you say your health is:

□1 Excellent □2 Very good □3 Good □4 Fair □5 Poor


The following questions are about activities you might do during a typical day. Does your health now
limit you in these activities? If so, how much?

YES, YES, NO, not


limited limited limited
a lot a little at all
2. Moderate activities such as moving a table, pushing □1 □2 □3
a vacuum cleaner, bowling, or playing golf.
3. Climbing several flights of stairs. □1 □2 □3
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?

YES NO
4. Accomplished less than you would like. □1 □2
5. Were limited in the kind of work or other activities. □1 □2
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)?

YES NO
6. Accomplished less than you would like. □1 □2
7. Did work or activities less carefully than usual. □1 □2
8. During the past 4 weeks, how much did pain interfere with your normal work (including work outside
the home and housework)?

□1 Not at all □2 A little bit □3 Moderately □4 Quite a bit □5 Extremely


These questions are about how you have been feeling 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…

All of Most A good Some A little None


the of the bit of of the of the of the
time time the time time time time
9. Have you felt calm & peaceful? □1 □2 □3 □4 □5 □6
10. Did you have a lot of energy? □1 □2 □3 □4 □5 □6
11. Have you felt down-hearted and □1 □2 □3 □4 □5 □6
blue?
12. During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities (like visiting friends, relatives, etc.)?

□1 All of the time □2 Most of the time □3 Some of the time □4 A little of the time □5 None of the time

Patient name: Date: PCS: MCS:


__________________________________________________________________________
Visit type (circle one)
Preop 6 week 3 month 6 month 12 month 24 month Other:_________

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