SF-12 (Short form)

SF-12 (Short Form)

Question 1	In general, would you say your health is excellent, very good, good, fair, or poor?		Excellent ...		0
			Very Good ...		0
			Good ...		0
			Fair ...		0
			Poor ...		-2

Question 2	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? First, moderate activities such as moving a table, pushing a vacuum cleaner, bowling or playing golf. Does your health now limit you a lot, limit you a little, or not limit you at all.

			Limited a lot ...		4
			Limited a little ...		2
			Not limited at all ...		0

Question 3	Climbing several flights of stairs. Does your health now limit you a lot, limit you a little, or not limit you at all?

			Limited a lot ...		3
			Limited a little ...		1
			Not limited at all ...		0

Question 4	During the past four weeks, have you accomplished less than you would like as a result of your physical health?


			No ...		0
			Yes ...		1

Question 5	During the past four weeks, were you limited in the kind of work or other regular activities you do as a result of your physical health?


			No ...		0
			Yes ...		2

Question 6	During the past four weeks, have you accomplished less than you would like to as a result of any emotional problems, such as feeling depressed or anxious?


			No ...		0
			Yes ...		-7

Question 7	During the past four weeks, did you not do work or other regular activities as carefully as usual as a result of any emotional problems such as feeling depressed or anxious?


			No ...		0
			Yes ...		-6

Question 8	During the past four weeks, how much did pain interfere with your normal work, including both work outside the home and housework? Did it interfere not at all, slightly, moderately, quite a bit, or extremely?		Not at all ...		0
			Slightly ...		1
			Moderately ...		1
			Quite a bit ...		2
			Extremely ...		1

Question 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 time during the past 4 weeks have you felt calm and peaceful? All of the time, most of the time, a good bit of the time, some of the time, a little of the time, or none of the time?		All of the time ...		0
			Most of the time ...		-2
			A good bit of the time ...		-4
			Some of the time ...		-6
			A little of the time ...		-8
			None of the time ...		-10

Question 10	How much of the time during the past 4 weeks did you have a lot of energy? All of the time, most of the time, a good bit of the time, some of the time, a little of the time, or none of the time?		All of the time ...		0
			Most of the time ...		-1
			A good bit of the time ...		-2
			Some of the time ...		-3
			A little of the time ...		-5
			None of the time ...		-6

Question 11	How much time during the past 4 weeks have you felt down? All of the time, most of the time, a good bit of the time, some of the time, a little of the time, or none of the time?		All of the time ...		-16
			Most of the time ...		-11
			A good bit of the time ...		-8
			Some of the time ...		-5
			A little of the time ...		-2
			None of the time ...		0

Question 12	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? All of the time, most of the time, some of the time, a little of the time, or none of the time?		All of the time ...		-6
			Most of the time ...		-8
			Some of the time ...		-6
			A little of the time ...		-3
			None of the time ...		0

Edited by Gavin Andrews MD, UNSW, Jan 03
© 2003 CRUfAD