Sf-36 Health Survey (Page 3 of 4) in pdf

6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal

social activities with family, friends, neighbours or groups?

(circle one)

Not at all

……………………………………………………………………………………

Slightly

……………………………………………………………………………………

Moderately

……………………………………………………………………………………

Quite a bit

……………………………………………………………………………………

Extremely

……………………………………………………………………………………

7. How much bodily pain have you had during the past 4 weeks?

(circle one)

None

…………………………………………………………………………………….

Very mild

…………………………………………………………………………………….

Mild

…………………………………………………………………………………….

Moderate

…………………………………………………………………………………….

Severe

…………………………………………………………………………………….

Very severe

…………………………………………………………………………………….

8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the

home and housework)?

(circle one)

Not at all

…………………………………………………………………………………..

A little bit

…………………………………………………………………………………..

Moderately

…………………………………………………………………………………..

Quite a bit

…………………………………………………………………………………..

Extremely

…………………………………………………………………………………..

Sf-36 Health Survey Page 3