SHORT FORM SURVEY INSTRUMENT (SF-36)

Please fill-out the form below or download the PDF here.

Download SF-36 HERE

Step 1 of 5

20%

Participant Details

Please complete all sections.

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

RAND 36-Item Health Survey 1.0 Questionnaire Items

Choose one option for each questionnaire item.

1. In general, would you say your health is:(Required)

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?(Required)

1 - Much better now than one year ago

2 - Somewhat better now than one year ago

3 - About the same

4 - Somewhat worse now than one year ago

5 - Much worse now than one year ago

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?

3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports(Required)

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited at all

4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf(Required)

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited at all

5. Lifting or carrying groceries(Required)

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited at all

6. Climbing several flights of stairs(Required)

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited at all

7. Climbing one flight of stairs(Required)

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited at all

8. Bending, kneeling, or stooping(Required)

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited at all

9. Walking more than a mile(Required)

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited at all

10. Walking several blocks(Required)

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited at all

11. Walking one block(Required)

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited at all

12. Bathing or dressing yourself(Required)

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 daily activities as a result of your physical health?

13. Cut down the amount of time you spent on work or other activities(Required)

1 - Yes

2 - No

14. Accomplished less than you would like(Required)

1 - Yes

2 - No

15. Were limited in the kind of work or other activities(Required)

1 - Yes

2 - No

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

1 - Yes

2 - No

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)?

17. Cut down the amount of time you spent on work or other activities(Required)

1 - Yes

2 - No

18. Accomplished less than you would like(Required)

1 - Yes

2 - No

19. Didn't do work or other activities as carefully as usual(Required)

1 - Yes

2 - No

20. 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?(Required)

1 - Not at all

2 - Slightly

3 - Moderately

4 - Quite a bit

5 - Extremely

21. How much bodily pain have you had during the past 4 weeks?(Required)

1 - None

2 - Very mild

3 - Mild

4 - Moderate

5 - Severe

6 - Very severe

22. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?(Required)

1 - Not at all

2 - Slightly

3 - Moderately

4 - Quite a bit

5 - Extremely

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...

23. Did you feel full of pep?(Required)

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

24. Have you been a very nervous person?(Required)

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

25. Have you felt so down in the dumps that nothing could cheer you up?(Required)

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

26. Have you felt calm and peaceful?(Required)

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

27. Did you have a lot of energy?(Required)

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

28. Have you felt downhearted and blue?(Required)

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

29. Did you feel worn out?(Required)

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

30. Have you been a happy person?(Required)

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

31. Did you feel tired?(Required)

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

32. 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.)?(Required)

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

How TRUE or FALSE is each of the following statements for you.

33. I seem to get sick a little easier than other people(Required)

1 - Definitely true

2 - Mostly true

3 - Don't know

4 -Mostly false

5 - Definitely false

34. I am as healthy as anybody I know(Required)

1 - Definitely true

2 - Mostly true

3 - Don't know

4 -Mostly false

5 - Definitely false

35. I expect my health to get worse(Required)

1 - Definitely true

2 - Mostly true

3 - Don't know

4 -Mostly false

5 - Definitely false

36. My health is excellent(Required)

1 - Definitely true

2 - Mostly true

3 - Don't know

4 -Mostly false

5 - Definitely false

CAPTCHA

SHORT FORM SURVEY INSTRUMENT (SF-36)

Please fill-out the form below or download the PDF here.

Participant Details

RAND 36-Item Health Survey 1.0 Questionnaire Items

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?

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?

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)?

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...

How TRUE or FALSE is each of the following statements for you.

COMPASS REHAB

Book an Appointment