Form Sf-12 - Health Survey Template
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1SF-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:
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Excellent
Very good
Good
Fair
Poor
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2
3
4
5
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
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2.
Moderate activities such as moving a table, pushing
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3
a vacuum cleaner, bowling, or playing golf.
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3. Climbing several flights of stairs.
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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
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4. Accomplished less than you would like.
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2
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5. Were limited in the kind of work or other activities.
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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
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6. Accomplished less than you would like.
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2
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7. Did work or activities less carefully than usual.
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2
8. During the past 4 weeks, how much did pain interfere with your normal work (including work outside
the home and housework)?
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Not at all
A little bit
Moderately
Quite a bit
Extremely
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2
3
4
5
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
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9. Have you felt calm & peaceful?
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3
4
5
6
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10. Did you have a lot of energy?
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2
3
4
5
6
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11. Have you felt down-hearted and
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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.)?
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All of the time
Most of the time
Some of the time
A little of the time
None of the time
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2
3
4
5
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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Parent category: Life