RAND SF-36v2 Health Survey

This  36 item Health Survey was developed at RAND as part of the Medical Outcomes Study.

Instructions for completing the questionnaire:
Please submit an answer for each question. Some questions may look like others, but each one is different. Please take the time to read and answer each question carefully by selecting the choice that best represents your response. Pressing the "Submit" button at the end of the form will automatically send the information to Sleep Professionals Network. All information is kept strictly confidential.

Patient First Name: 
Patient Last Name: 
Patient Phone:

1) In general, would you say your health is:
Excellent Very Good Good Fair Poor

2) Compared to one year ago, how would you rate your health in 
    general now ?
Much better than one year ago Somewhat better than one year ago About the same as one year ago Somewhat worse than one year ago Much worse than one year ago

3) 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?
  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 a mile:
h) Walking several hundred yards:
i) Walking one hundred yards:
j) Bathing or dressing yourself:

4) During the past 4 weeks, how much of the time have you had any of the
    following problems with your work or other regular daily activities as a result
    of your physical problems?
  All of the time Most of the time Some of the  time A little of the time None of the time
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, how much of the time 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) ?
  All of the time Most of the time Some of the  time A little of the time None of the time
a) Cut down on the amount of time you spent on work or other activities:
b) Accomplished less than you would like:
c) Did work or other activities less carefully than usual:

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?
Not at all Slightly Moderately Quite a bit Extremely

7) How much bodily pain have you had during the past 4 weeks?
None Very Mild Mild Moderate Severe 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) ?
Not at all Slightly Moderately Quite a bit 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 weeks: 
  All of the time Most of the time Some of the  time A little of the time None of the time
a) did you feel full of life?
b) have you been very nervous?
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 depressed?
g) did you feel worn out?
h) have you been happy?
i) did you feel tired?

10) During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.) ?
All of the time Most of the time Some of the  time A little of the time None of the time

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) 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):

Please press this button only once to submit the form. All information is kept strictly confidential.

 Thank you for participating !