SF-36

INSTRUCTIONS: This survey asks 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.
Please answer every question by marking the answer as indicated. If you are unsure about how to answer a question,
please give the best answer you can.
When complete, please return the questionnaire in the envelope provided.

1. In general, would you say your health is:
(circle one)
Excellent ………………………………………………………………………………….. 1
Very good …………………………………………………………………………………. 2
Good …………………………………………………………………………………. 3
Fair …………………………………………………………………………………. 4
Poor …………………………………………………………………………………. 5
2. Compared to one year ago, how would you rate your health in general now?
(circle one)
Much better now than one year ago ………………………………………………………. 1
Somewhat better than one year ago ………………………………………………………. 2
About the same as one year ago ………………………………………………………. 3
Somewhat worse than one year ago ………………………………………………………. 4
Much worse now than one year ago ………………………………………………………. 5
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?
(circle one number on each line)
Activities Yes, limited
a lot
Yes, limited a
little
No, not
limited at all
Vigorous activities, such as running, lifting heavy
objects, participating in strenuous sports. 1 2 3
Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling or playing golf 1 2 3
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 2 3
Bathing or dressing yourself
1 2 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
activities 1 2
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
took extra effort 1 2
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
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 …………………………………………………………………………………… 1
Slightly …………………………………………………………………………………… 2
Moderately …………………………………………………………………………………… 3
Quite a bit …………………………………………………………………………………… 4
Extremely …………………………………………………………………………………… 5
7. How much bodily pain have you had during the past 4 weeks?
(circle one)
None ……………………………………………………………………………………. 1
Very mild ……………………………………………………………………………………. 2
Mild ……………………………………………………………………………………. 3
Moderate ……………………………………………………………………………………. 4
Severe ……………………………………………………………………………………. 5
Very severe ……………………………………………………………………………………. 6
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 ………………………………………………………………………………….. 1
A little bit ………………………………………………………………………………….. 2
Moderately ………………………………………………………………………………….. 3
Quite a bit ………………………………………………………………………………….. 4
Extremely ………………………………………………………………………………….. 5
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
the time
Most of the
time
A good bit
of the time
Some of
the time
A little of
the time
None of the
time
Did you feel full of life?
1 2 3 4 5 6
Have you been a very
nervous person? 1 2 3 4 5 6
Have you felt so down in
the dumps that nothing
could cheer you up?
1 2 3 4 5 6
Have you felt calm and
peaceful? 1 2 3 4 5 6
Did you have a lot of
energy? 1 2 3 4 5 6
Have you felt
downhearted and low? 1 2 3 4 5 6
Did you feel worn out?
1 2 3 4 5 6
Have you been a happy
person? 1 2 3 4 5 6
Did you feel tired?
1 2 3 4 5 6
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.)?
(circle one)
All of the time …………………………………………………………………………………. 1
Most of the time …………………………………………………………………………………. 2
Some of the time …………………………………………………………………………………. 3
A little of the time …………………………………………………………………………………. 4
None of the time …………………………………………………………………………………. 5
11. How TRUE or FALSE is each of the following statements to you?
(circle one number on each line)
Definitely true Mostly true Don’t know Mostly false Definitely false
I seem to get ill
more easily than
other people
1 2 3 4 5
I am as healthy as
anybody I know 1 2 3 4 5
I expect my health
to get worse 1 2 3 4 5
My health is
excellent 1 2 3 4 5