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In general, would you say your health is: (Please tick one box.)
Excellent -
Very Good - III
Good - I
Fair -
Poor -
Compared to one year ago , how would you rate your health in general now
Much better than one year ago -I
Somewhat better now than one year ago - III
About the same as one year ago -
Somewhat worse now than one year ago -
Much worse now than one year ago -
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?
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
1 -
2 - III
3 - I
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
1 -
2 - I
3 - III
Lifting or carrying groceries
1 -
2 - I
3 - III
Climbing several flights of stairs
1 -
2 -
3 - IIII
Climbing one flight of stairs Bending, kneeling, or stooping
1 -
2 -
3 - IIII
Waling more than a mile
1 -
2 -
3 - IIII
Walking several blocks
1 -
2 -
3 - IIII
Walking one block
1 -
2 -
3 - IIII
Bathing or dressing yourself
1 -
2 -
3 - IIII
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 your physical health ?
Cut down on the amount of time you spent on work or other activities
Yes -
No -IIII
Accomplished less than you would like
Yes - I
No -III
Were limited in the kind of work or other activities
Yes - I
No -III
Had difficulty performing the work or other activities (for example, it took extra effort)
Yes - I
No -III
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
Cut down on the amount of time you spent on work or other activities
Yes -
No -IIII
Accomplished less than you would like
Yes -
No