Form Sf-36 - Developed By Rand As Part Of The Medical Outcomes Study - Used By Permission - Health Survey

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SF-36® Health Survey
Developed by RAND as part of the Medical Outcomes Study, used by permission
Name ______________________________________ Date __________________
s:!
1.!
In general, would you say your health i
Excellent
Very Good
Good
Fair
Poor
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❍
❍
❍
❍
2.!
Compared to one year ago, how would you rate your health now?
Much better now
Somewhat better
About the same
Somewhat worse
Much worse now
than one year ago
now than one year
now as one year
than one year ago
than one year ago
ago
ago
❍
❍
❍
❍
❍
3.
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
a. Vigorous activities, such as running, lifting heavy objects,
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❍
❍
participating in strenuous sports.
b. Moderate activities, such as moving a table, pushing a vacuum
❍
❍
❍
cleaner, bowling, or playing golf?
❍
❍
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c. Lifting or carrying groceries.
❍
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d. Climbing several flights of stairs.
❍
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e. Climbing one flight of stairs.
❍
❍
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f. Bending, kneeling or stooping.
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g. Walking more than one mile.
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h. Walking several blocks.
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i. Walking one block.
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j. Bathing or dressing yourself.

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