INSTITUTE FOR ALGORITHMIC MEDICINE
Short Form-36(SF-36)Helath Survey   

Purpose: To use the Short-Form-36 (SF-36) as a general  health survey instrument.   About Algorithm
             

Instructions:
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 every question by marking the answer as indicated. If you are unsure about how to answer a question,please give the best answer you can.
      excellent    very good    good     fair   Poor
1 In general would you say your    health is
     much better somewhat  better  about the  same  somewhat worse  much worse
2 Compared to one year ago, how    would  you rate your health in      general now?
  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?
 

  Yes, limited
      a lot

  Yes, limited
     a little

      No, not
 limited at all

a Vigorous activities,such as    running,lifting heavy objects,    participating in strenuous
   sports.     

  

b Moderate activities,such as    moving a table,pushing a
   vacuum cleaner, bowling or    playing golf.

  
c  Lifting or carrying groceries.  
d  Climbing several flights of     stairs.  
e  Climbing one flight of stairs.  
f  Bending, kneeling, or stooping.  
g  Walking more than one mile.  
h  walking several blocks  
i  Bathing or dressing yourself.  
  4. 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?
  Yes No    

a Cut down on the amount of    time you spent on  work or    other activities.

  
b  Accomplished less than     you would like.  
c  Were limited in the kind of    work or other activities.  

d  Had difficulty performing the    work or other activities (for    example, it took extra effort).

  
  5. During the past 4 weeks, have you had any of the following problems with your work or other regular 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.  
b Accomplished less than you    would  like.  
c Didn't do work or other   activities as carefully as usual.  
    not at all    slightly   moderately   quite a bit    extremely

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?
  
     none   very mild   mild   moderate   severe  very severe
7.How much bodily pain have    you had during the past 4    weeks?
    not at all   a little bit    moderately   quite a bit  extremely

8 During the past 4 weeks, how
   much did pain interfere with    your normal work (including both    work outside he home
   and housework)?
   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 weeks:
    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
a Did you feel full of pep?
b Have you been a very    nervous person?
c Have you felt so down in the   dumps that nothing could   cheer you  up?
d Have you felt calm    and peaceful?
e Did you have a lot of energy?
f Have you felt downhearted   and blue?
g Did you feel worn out?
h Have you been a happy    person?
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 emotional health      or problems interfered with      your  social activities      with friends (like visiting,      relatives,etc.)?
   11. How TRUE or FALSE is each of the following statements for you?
    definitely      true     mostly true     don't  know    mostly     false    definitely      false
a I seem to get sick a little   easier       than other people.
b I am as healthy as anybody I    know
c I expect my health to get    worse.
d My health is excellent.
   
       About Algorithm