| Question | Response |
|---|---|
| Date of assessment |
QS.QSDTC |
| 1. In general, would you say your health is: | Excellent Very Good Good Fair Poor |
| 2. Compared to one year ago, how would you rate your health now? | Much better now than one year ago Somewhat better now than one year ago About the same as one year ago Somewhat worse now than one year ago Much worse now than one year ago |
| 3.a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports | Yes, limited a lot Yes, limited a little No, not limited at all |
| 3.b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf | Yes, limited a lot Yes, limited a little No, not limited at all |
| 3.c. Lifting or carrying groceries | Yes, limited a lot Yes, limited a little No, not limited at all |
| 3.d. Climbing several flights of stairs Yes, | Yes, limited a lot Yes, limited a little No, not limited at all |
| 3.e. Climbing one flight of stairs | Yes, limited a lot Yes, limited a little No, not limited at all |
| 3.f. Bending, kneeling, or stooping | Yes, limited a lot Yes, limited a little No, not limited at all |
| 3.g. Walking more than a mile | Yes, limited a lot Yes, limited a little No, not limited at all |
| 3.h. Walking several hundred yards | Yes, limited a lot Yes, limited a little No, not limited at all |
| 3.i. Walking one hundred yards | Yes, limited a lot Yes, limited a little No, not limited at all |
| 3.j. Bathing or dressing yourself | Yes, limited a lot Yes, limited a little No, not limited at all |
| 4.a. Cut down on the amount of time you spent on work or other activities | All of the time Most of the time Some of the time A little of the time None of the time |
| 4.b. Accomplished less than you would like | All of the time Most of the time Some of the time A little of the time None of the time |
| 4.c. Were limited in the kind of work or other activities | All of the time Most of the time Some of the time A little of the time None of the time |
| 4.d. Had difficulty performing the work or other activities (for example, it took extra effort) | All of the time Most of the time Some of the time A little of the time None of the time |
| 5.a. Cut down on the amount of time you spent on work or other activities | All of the time Most of the time Some of the time A little of the time None of the time |
| 5.b. Accomplished less than you would like | All of the time Most of the time Some of the time A little of the time None of the time |
| 5.c. Didn't do work or other activities as carefully as usual | All of the time Most of the time Some of the time A little of the time None of the time |
| 6. 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? | Not at all Slightly Moderately Quite a bit Extremely |
| 7. How much bodily pain have you had during the past 4 weeks? | None Very mild Mild Moderate Severe Very severe |
| 8. 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 Slightly Moderately Quite a bit Extremely |
| 9.a. Did you feel full of life? | All of the time Most of the time Some of the time A little of the time None of the time |
| 9.b. Have you been very nervous? | All of the time Most of the time Some of the time A little of the time None of the time |
| 9.c. Have you felt so down in the dumps that nothing could cheer you up? | All of the time Most of the time Some of the time A little of the time None of the time |
| 9.d. Have you felt calm and peaceful? | All of the time Most of the time Some of the time A little of the time None of the time |
| 9.e. Did you have a lot of energy? | All of the time Most of the time Some of the time A little of the time None of the time |
| 9.f. Have you felt downhearted and depressed? | All of the time Most of the time Some of the time A little of the time None of the time |
| 9.g. Did you feel worn out? | All of the time Most of the time Some of the time A little of the time None of the time |
| 9.h. Have you been happy? | All of the time Most of the time Some of the time A little of the time None of the time |
| 9.i. Did you feel tired? | All of the time Most of the time Some of the time A little of the time None of the time |
| 10. 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 Most of the time Some of the time A little of the time None of the time |
| 11.a. I seem to get sick a little easier than other people | Definitely true Mostly true Don?t know Mostly false Definitely false |
| 11.b. I am as healthy as anyone I know | Definitely true Mostly true Don?t know Mostly false Definitely false |
| 11.c. I expect my health to get worse | Definitely true Mostly true Don?t know Mostly false Definitely false |
| 11.d. My health is excellent | Definitely true Mostly true Don?t know Mostly false Definitely false |