Health Survey for Dialysis Patients (SF36)
Today’s
Date:__________
Name:
Last:_______________________ First:
_______________ Date of Birth:
__________
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.
Please answer these questions by “check-marking” your choice. Please select only one choice for each item.
1-
In general, would you say your health is:
› 1. Excellent › 2. Very good › 3. Good › 4. Fair › 5. Poor
2- Compared to ONE YEAR AGO, how would you rate your
health in general NOW?
|
› 1. MUCH BETTER than one year ago. › 2. Somewhat BETTER now than one year ago. › 3. About the SAME as one year ago. › 4. Somewhat WORSE now than one year ago. › 5. MUCH WORSE now than one year ago. |
|
3- The following items are about
activities you might do during a typical day.
Does your health now limit you
in these activities? If so, how much?
|
Activities |
1. Yes,
Limited A Lot |
2. Yes, Limited |
3. No, |
|
a) Vigorous activities, such as running, lifting heavy
objects, participating in strenuous sports? |
› 1. Yes, limited a lot |
› 2. Yes, limited a little |
› 3. No, not limited at all |
|
b) 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 |
|
c) Lifting or carrying groceries? |
› 1. Yes, limited a lot |
› 2. Yes, limited a little |
› 3. No, not limited at all |
|
d) Climbing several flights of stairs? |
› 1. Yes, limited a lot |
› 2. Yes, limited a little |
› 3. No, not limited at all |
|
e) Climbing one flight of stairs? |
› 1. Yes, limited a lot |
› 2. Yes, limited a little |
› 3. No, not limited at all |
|
f) Bending, kneeing or stooping? |
› 1. Yes, limited a lot |
› 2. Yes, limited a little |
› 3. No, not limited at all |
|
g) Walking more than a mile? |
› 1. Yes, limited a lot |
› 2. Yes, limited a little |
› 3. No, not limited at all |
|
h) Walking several blocks? |
› 1. Yes, limited a lot |
› 2. Yes, limited a little |
› 3. No, not limited at all |
|
i) Walking one block? |
› 1. Yes, limited a lot |
› 2. Yes, limited a little |
› 3. No, not limited at all |
|
j) Bathing or dressing yourself? |
› 1. Yes, limited a lot |
› 2. Yes, limited a little |
› 3. No, not limited at all |
4- 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?
|
|
Yes |
No |
|
a) Cut down on the amount of time you spent on work or
other activities? |
› 1. yes |
› 2. No |
|
b) Accomplished less than
you would like? |
› 1. yes |
› 2. No |
|
c) Were limited in the kind of work or other activities? |
› 1. yes |
› 2. No |
|
d) Had difficulty performing the work or other activities (for example
it took extra effort)? |
› 1. yes |
› 2. No |
5. During the past
4 weeks, 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)?
|
|
Yes |
No |
|
a) Cut down on the amount of time you spent on work or
other activities? |
› 1. yes |
› 2. No |
|
b) Accomplished less than
you would like? |
› 1. yes |
› 2. No |
|
|
› 1. yes |
› 2. No |
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?
› 1. Not at all › 2. Slightly › 3. Moderately › 4. Quite a bit › 5. Extremely
7. 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
8. 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
9. 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 week …
|
|
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 |
|
a) Did you feel full of pep? |
› 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 |
|
b) Have you been a very nervous person? |
› 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 |
|
c) Have you felt so down in the dumps that nothing could cheer you up? |
› 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 |
|
d) 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 |
|
e) Did 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 |
|
f) 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 |
|
g) Do you feel worn out? |
› 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 |
|
h) Have you been a happy person? |
› 1. All of the time |
› 2. Most of the time |