Study participants baseline interview

SHIPS
Page 1

Baseline Interview: SF-12
Record ID.

__________________________________

Baseline Interview: SF-12 Health Survey
(Please repeat the reminder below if it has not been provided during this interview period.)
Reminder about resources to help you cope with distress.  
When you enrolled in this study, you were provided with a list of resources to help you cope
with negative feelings and reactions to these interviews.  These resources can also help you
with other problems in your life not related to the study.
If you do not remember receiving this information, we will provide it to you immediately
following this interview.

Interview prompt:
"This survey asks for your views about your health. This information will help keep track of
how you feel and how well you are able to do your usual activities."
"Answer each question by choosing just one answer. If you are unsure how to answer a
question, please give the best answer you can."
1. In gneral, would say your health is:

Excellent
Very good
Good
Fair
Poor

Questions 2 & 3: The following two questions are about activities you might do during a
typical day. Does you health now limit you in these activities. If so, how much?
2. Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or playing golf.

YES: limited a lot
YES: Limited a little
NO: no limited at all

3. Climbing several flights of stairs.

YES: limited a lot
YES: Limited a little
NO: no limited at all

05/01/2024 12:10pm

projectredcap.org

Page 2

Questions 4 & 5: During the past 4 weeks, have you had any of the following problems with
your work or other regular daily acitivites as a result of your physical health?
4. Accomplished less than you would like.

Yes
No

5. Were limited in the kind of work or other
activities.

Yes
No

Questions 6 & 7:  During the past 4 weeks, have you had any of the following problems with
your work or other regular daily acitivites as a result of any emotional problems (such as
feeling depressed or anxious)?
6. Accomplished less than you would like.

Yes
No

7. Did work or activities less carefully than usual.

Yes
No

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

Not at all
A little bit
Moderately
Quite a bit
Extremely

Questions 9, 10, and 11.  These questions are about how you have been feeling 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...
9. Have you felt calm and peaceful?

How much of the time during the past 4 weeks...
10. Did you have a lot of energy?

How much of the time during the past 4 weeks...
11. Did you felt down-hearted and blue?

05/01/2024 12:10pm

All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time

projectredcap.org

Page 3

12. 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.)?

How do you feel about life in general?

All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
Terrible

Delighted
(Place a mark on the scale above)

05/01/2024 12:10pm

projectredcap.org