16 Sf 12

ID NUMBER:

FORM CODE: SFE VERSION: A 4/30/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 05 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL SF-12v2™ Health Survey

ID NUMBER:

FORM CODE: SFE VERSION: A 4/30/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Mark the appropriate box for the response. Unless instructed, mark ONLY one response.

This survey asks for your views about your health. This information will help you keep track of how you feel and how well you are able to do your usual activities. Answer every question by selecting the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can.

1. In general, would you say your health is:

Excellent 1 Very good 2 Good 3 Fair 4 Poor 5

2. 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?

Yes, Yes, No, not limited limited limited

a lot a little at all

1. Moderate activities, such as moving a table, pushing a

vacuum cleaner, bowling, or playing golf 1 2 3

2. Climbing several flights of stairs 1 2 3

3. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

All of Most of Some of A little of None of

the time the time the time the time the time

1. Accomplished less than you would like 1 2 3 4 5

2. Were limited in the kind of work or other

activities 1 2 3 4 5

4. During the past 4 weeks, how much of the time 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)?

All of Most of Some of A little of None of

the time the time the time the time the time

1. Accomplished less than you would like 1 2 3 4 5

2. Didn’t do work or activities as carefully 1 2 3 4 5

as usual

5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

Not at all 1

A little bit 2

Moderately 3

Quite a bit 4

Extremely 5

6. 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 Most of Some of A little of None of

the time the time the time the time the time

1. Have you felt calm and peaceful? 1 2 3 4 5

2. Did you have a lot of energy? 1 2 3 4 5

3. Have you felt downhearted and depressed? 1 2 3 4 5

7. 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.)?

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

SF-12v2 Health Survey (SFE) Page 0 of 2