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Assistant Policy Analyst; Ph.D. Candidate, Pardee RAND Graduate School
Choose one option for each questionnaire item.
1. In general, would you say your health is:
1 - Excellent
2 - Very good
3 - Good
4 - Fair
5 - Poor
2. Compared to one year ago, how would you rate your health in general now?
1 - Much better now than one year ago
2 - Somewhat better now than one year ago
3 - About the same
4 - Somewhat worse now than one year ago
5 - Much worse now than one year ago
The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
5. Lifting or carrying groceries
6. Climbing several flights of stairs
7. Climbing one flight of stairs
8. Bending, kneeling, or stooping
9. Walking more than a mile
10. Walking several blocks
11. Walking one block
12. Bathing or dressing yourself
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?
13. Cut down the amount of time you spent on work or other activities
14. Accomplished less than you would like
15. Were limited in the kind of work or other activities
16. Had difficulty performing the work or other activities (for example, it took extra effort)
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)?
17. Cut down the amount of time you spent on work or other activities
18. Accomplished less than you would like
19. Didn't do work or other activities as carefully as usual
20. 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?
1 - Not at all
2 - Slightly
3 - Moderately
4 - Quite a bit
5 - Extremely
21. How much bodily pain have you had during the past 4 weeks?
1 - None
2 - Very mild
3 - Mild
4 - Moderate
5 - Severe
6 - Very severe
22. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
2 - A little bit
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...
23. Did you feel full of pep?
24. Have you been a very nervous person?
25. Have you felt so down in the dumps that nothing could cheer you up?
26. Have you felt calm and peaceful?
27. Did you have a lot of energy?
28. Have you felt downhearted and blue?
29. Did you feel worn out?
30. Have you been a happy person?
31. Did you feel tired?
32. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
1 - All of the time
2 - Most of the time
3 - Some of the time
4 - A little of the time
5 - None of the time
How TRUE or FALSE is each of the following statements for you.
33. I seem to get sick a little easier than other people
34. I am as healthy as anybody I know
35. I expect my health to get worse
36. My health is excellent