mswithyourworkorotherregulardailyactivitiesasaresultofyourphysicalhealth
13Cutdow
theamou
toftimeyouspe
to
workorotheractivities
YesNo12
14Accomplishedlesstha
youwouldlike
12
15Werelimitedi
theki
dofworkorotheractivities
12
16Haddifficultyperformi
gtheworkorotheractivitiesforexampleittookextraeffort
12
Duri
gthepast4weekshaveyouhada
yofthefollowi
gproblemswithyourworkorotherregulardailyactivitiesasaresultofa
yemotio
alproblemssuchasfeeli
gdepressedora
xious
fYesNo
17Cutdow
theamou
toftimeyouspe
to
workorotheractivities
12
18Accomplishedlesstha
youwouldlike
12
19Did
tdoworkorotheractivitiesascarefullyasusual
12
20Duri
gthepast4weekstowhatexte
thasyourphysicalhealthoremotio
alproblemsi
terferedwithyour
ormalsocialactivitieswithfamilyfrie
ds
eighborsorgroups
1Notatall
2Slightly
3Moderately
4Quiteabit
5Extremely
f21Howmuchbodilypai
haveyouhadduri
gthepast4weeks1No
e2Verymild3Mild4Moderate5Severe6Verysevere
22Duri
gthepast4weekshowmuchdidpai
i
terferewithyour
ormalworki
cludi
gbothworkoutsidethehomea
dhousework
1Notatall
f2Alittlebit
3Moderately
4Quiteabit
5Extremely
Thesequestio
sareabouthowyoufeela
dhowthi
gshavebee
withyouduri
gthepast4weeksForeachquestio
pleasegivetheo
ea
swerthatcomesclosesttothewayyouhavebee
feeli
g
Howmuchofthetimeduri
gthepast4weeks
23Didyoufeelfullofpep
AlloftheMostoftheAgoodbitoftheSomeoftheAlittleoftheNo
eofthe
time
time
time
time
time
time
1
2
3
4
5
6
24Haveyoubee
avery
ervousperso

1
2
3
4
5
6
25Haveyoufeltsodow
i
thedumpsthat
othi
gcould
cheeryouup
1
2
3
4
5
6
f26Haveyoufeltcalma
dpeaceful27Didyouhavealotofe
ergy28Haveyoufeltdow
hearteda
dblue29Didyoufeelwor
out30Haveyoubee
ahappyperso
31Didyoufeeltired
AlloftheMostoftheAgoodbitoftheSomeoftheAlittleoftheNo
eofthe
time
time
time
time
time
time
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
32Duri
gthepast4weekshowmuchofthetimehasyourphysicalhealthoremotio
alproblemsi
terferedwithyoursocialactivitieslikevisiti
gwithfrie
dsrelativesetc
1Allofthetime
2Mostofthetime
3Someofthetime
f4Alittleofthetime
5No
eofthetime
HowTRUEorFALSEiseachofthefollowi
gstateme
tsforyou
33Iseemtogetsickalittleeasiertha
otherpeople34Iamashealthyasa
ybodyIk
ow35Iexpectmyhealthtogetworse36Myhealthisexcelle
t
Defi
itelytrueMostlytrueDo
tk
owMostlyfalseDefi
itelyfalse
1
2
3
4
5
1
2
3
4
5
1
2
r