SF-36
2
g. Walking more than one mile.
q
Yes, limited a lot.
q
Yes, limited a little.
q
No, not limited at all.
h. Walking several blocks.
q
Yes, limited a lot.
q
Yes, limited a little.
q
No, not limited at all.
i. Walking one block.
q
Yes, limited a lot.
q
Yes, limited a little.
q
No, not limited at all.
j. Bathing or dressing yourself.
q
Yes, limited a lot.
q
Yes, limited a little.
q
No, not limited at all.
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?
a. Cut down the amount of time you spent on work or other activities?
c Yes
c No
b. Accomplished less than you would like?
c Yes
c No
c. Were limited in the kind of work or other activities
c Yes
c No
d. Had difficulty performing the work or other activities (for example, it took extra time)
c Yes
c No
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)?
a. Cut down the amount of time you spent on work or other activities?
c Yes
c No
b. Accomplished less than you would like
c Yes
c No
c. Didn't do work or other activities as carefully as usual
c Yes
c No
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, neighbors, or groups?
q
Not at all
q
Slightly
q
Moderately
q
Quite a bit
q
Extremely
7. How much bodily pain have you had during the past 4 weeks?
q
Not at all
q
Slightly
q
Moderately
q
Quite a bit
q
Extremely