Table 4 Twelve-item Short-Form Health Survey (SF-12)
Items | Score | Grading system |
|---|---|---|
In general, would you say your health is? | 1 | Excellent |
2 | Very good | |
3 | Good | |
4 | Fair | |
5 | Poor | |
The following two questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? | ||
 Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? | 1 | Yes, limited a lot |
2 | Yes, limited a little | |
3 | No, not limited at all | |
 Climbing several flights of stairs? | 1 | Yes, limited a lot |
2 | Yes, limited a little | |
3 | No, not limited at all | |
During the past 4 weeks have you had any of the following problems with your work or other regular activities as a result of your physical health? | ||
 Accomplished less than you would like? | 1 | Yes |
2 | No | |
 Are limited in the kind of work or other activities? | 1 | Yes |
2 | No | |
During the past 4 weeks, have you been limited in the kind of work you do or other regular activities as a result of any emotional problems (such as feeling depressed or anxious)? | ||
 Accomplished less than you would like? | 1 | Yes |
2 | No | |
 Cannot do work or other activities as carefully as usual? | 1 | Yes |
2 | No | |
During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? | 1 | Not at all |
2 | A little bit | |
3 | Moderately | |
4 | Quite a bit | |
5 | Extremely | |
The next three questions are about how you feel and how things have been 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? | ||
 Have you felt calm and peaceful? | 1 | All of the time |
2 | Most of the time | |
3 | A good bit of the time | |
4 | Some of the time | |
5 | A little of the time | |
6 | None of the time | |
 Do you have a lot of energy? | 1 | All of the time |
2 | Most of the time | |
3 | A good bit of the time | |
4 | Some of the time | |
5 | A little of the time | |
6 | None of the time | |
 Have you felt downhearted and blue? | 1 | All of the time |
2 | Most of the time | |
3 | A good bit of the time | |
4 | Some of the time | |
5 | A little of the time | |
6 | None of the time | |
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 | A good bit of the time | |
4 | Some of the time | |
5 | A little of the time | |
6 | None of the time | |