Form Sf-36 - Developed By Rand As Part Of The Medical Outcomes Study - Used By Permission - Health Survey Page 3

ADVERTISEMENT

9. !
These questions are about how you feel and how things have been with you
!
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
❍
❍
❍
❍
❍
❍
a. Did you feel full of pep?
❍
❍
❍
❍
❍
❍
b. Have you been a very nervous person?
❍
❍
❍
❍
❍
❍
c. Have you felt so down in the dumps that
nothing could cheer you up?
❍
❍
❍
❍
❍
❍
d. Have you felt calm and peaceful?
❍
❍
❍
❍
❍
❍
e. Did you have a lot of energy?
❍
❍
❍
❍
❍
❍
f. Have you felt downhearted and blue?
❍
❍
❍
❍
❍
❍
g. Did you feel worn out?
❍
❍
❍
❍
❍
❍
h. Have you been a happy person?
❍
❍
❍
❍
❍
❍
i. Did you feel tired?
10.!
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.)?
All of the time
Most of the time
Some of the time A little of the time None of the time
❍
❍
❍
❍
❍
11.!
How TRUE or FALSE is each of the following statements for you?
Definitely
Mostly
Donʼt
Mostly
Definitely
true
true
know
false
false
❍
❍
❍
❍
❍
a. I seem to get sick a little easier than other
people.
❍
❍
❍
❍
❍
b. I am as healthy as anybody I know
❍
❍
❍
❍
❍
c. I expect my health to get worse
❍
❍
❍
❍
❍
d. My health is excellent

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Boe-447 - Statement Pursuant To Section 6247 Of The California Sales And Use Tax Law Form Boe-447 - Statement Pursuant To Section 6247 Of The California Sales And Use Tax Law Financial
Form 8855 - Election To Treat A Qualified Revocable Trust As Part Of An Estate Form 8855 - Election To Treat A Qualified Revocable Trust As Part Of An Estate Financial
Form 8855 - Election To Treat A Qualified Revocable Trust As Part Of An Estate Form 8855 - Election To Treat A Qualified Revocable Trust As Part Of An Estate Financial
Form 8855 - Election To Treat A Qualified Revocable Trust As Part Of An Estate Form 8855 - Election To Treat A Qualified Revocable Trust As Part Of An Estate Financial
Form No. 15h - Declaration Under Section 197a(1c) Of The Income-tax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax Form No. 15h - Declaration Under Section 197a(1c) Of The Income-tax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax Financial
Form No. 15h - Declaration Under Section 197a(1c) Of The Income-tax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax Form No. 15h - Declaration Under Section 197a(1c) Of The Income-tax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax Financial
Form No. 15h - Declaration Under Section 197a(1c) Of The Incometax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax Form No. 15h - Declaration Under Section 197a(1c) Of The Incometax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax Financial
Form No. 15h - Declaration Under Section 197a(1c) Of The Incometax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax Form No. 15h - Declaration Under Section 197a(1c) Of The Incometax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax Financial
Form No. 15h - Declaration Under Section 197a(1c) Of The Incometax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax Form No. 15h - Declaration Under Section 197a(1c) Of The Incometax Act, 1961 To Be Made By An Individual Who Is Of The Age Of Sixty Years Or More Claiming Certain Receipts Without Deduction Of Tax Financial
Form No. 15h - Declaration Under Section 197a (1a) Of The Income Tax Act, 1961 To Be Made By A Persons Claiming Receipt Of Interest Other Than Form No. 15h - Declaration Under Section 197a (1a) Of The Income Tax Act, 1961 To Be Made By A Persons Claiming Receipt Of Interest Other Than "interest On Securities" Or Income In Respect Of Units Without Deduction Of Tax Financial

Related Categories

Parent category: Legal
Download
Go
Page of 4