Sf-36 Health Survey Page 2
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43. 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?
(circle one number on each line)
Activities
Yes, limited
Yes, limited a
No, not
a lot
little
limited at all
Vigorous activities, such as running, lifting heavy
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objects,
participating in strenuous sports.
Moderate activities, such as moving a table,
1
2
3
pushing a vacuum cleaner, bowling or playing golf
Lifting or carrying groceries
1
2
3
Climbing several flights of stairs
1
2
3
Climbing one flight of stairs
1
2
3
Bending, kneeling or stooping
1
2
3
Walking more than a mile
1
2
3
Walking half a mile
1
2
3
Walking one hundred yards
1
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3
Bathing or dressing yourself
1
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3
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 your physical health?
(circle one number on each line)
Yes
No
Cut down on the amount of time you spent on work or other
1
2
activities
Accomplished less than you would like
1
2
Were limited in the kind of work or other activities
1
2
Had difficulty performing the work or other activities (for example, it
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2
took extra effort
5.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)?
(circle one number on each line)
Yes
No
Cut down on the amount of time you spent on work or other activities
1
2
Accomplished less than you would like
1
2
Didn’t do work or other activities as carefully as usual
1
2
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Form Sf-36 - Developed By Rand As Part Of The Medical Outcomes Study - Used By Permission - Health Survey
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