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Assistant Policy Researcher; 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. For how long (if at all) has your health limited you in each of the following activities?
a. The kinds or amounts of vigorous activities you can do, like lifting heavy objects, running or participating in strenuous sports
b. The kinds or amounts of moderate activities you can do, like moving a table, carrying groceries, or bowling
c. Walking uphill or climbing a few flights of stairs
d. Bending, lifting, or stooping
e. Walking one block
f. Eating, dressing, bathing, or using the toilet
3. 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
4. Does your health keep you from working at a job, doing work around the house, or going to school?
1 - YES, for more than 3 months
2 - YES, for 3 months or less
3 - NO
5. Have you been unable to do certain kinds or amounts of work, housework, or schoolwork because of your health?
For each of the following questions, please mark the circle for the one answer that comes closest to the way you have been feeling during the past month.
6. How much of the time, during the past month, has you health limited your social activities (like visiting with friends or close relatives)?
7. How much of the time, during the past month, have you been a very nervous person?
8. During the past month, how much of the time have you felt calm and peaceful?
9. How much of the time, during the past month, have you felt downhearted and blue?
10. During the past month, how much of the time have you been a happy person?
11. How often, during the past month, have you felt so down in the dumps that nothing could cheer you up?
12. Please mark the circle that best describes whether each of the following statements is true or false for you.
a. I am somewhat ill
b. I am as healthy as anybody I know
c. My health is excellent
d. I have been feeling bad lately