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wtcqsf 时间:2021-01-26 阅读:()
SF-36QUESTIONNAIREName:Ref.
Dr:Date:ID#Age:Gender:M/FPleaseanswerthe36questionsoftheHealthSurveycompletely,honestly,andwithoutinterruptions.
GENERALHEALTH:Ingeneral,wouldyousayyourhealthis:ExcellentVeryGoodGoodFairPoorComparedtooneyearago,howwouldyourateyourhealthingeneralnowMuchbetternowthanoneyearagoSomewhatbetternowthanoneyearagoAboutthesameSomewhatworsenowthanoneyearagoMuchworsethanoneyearagoLIMITATIONSOFACTIVITIES:Thefollowingitemsareaboutactivitiesyoumightdoduringatypicalday.
DoesyourhealthnowlimityouintheseactivitiesIfso,howmuchVigorousactivities,suchasrunning,liftingheavyobjects,participatinginstrenuoussports.
Yes,LimitedalotYes,LimitedaLittleNo,NotLimitedatallModerateactivities,suchasmovingatable,pushingavacuumcleaner,bowling,orplayinggolfYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallLiftingorcarryinggroceriesYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallClimbingseveralflightsofstairsYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallClimbingoneflightofstairsYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallBending,kneeling,orstoopingYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallWalkingmorethanamileYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallWalkingseveralblocksYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallWalkingoneblockYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallBathingordressingyourselfYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallPHYSICALHEALTHPROBLEMS:Duringthepast4weeks,haveyouhadanyofthefollowingproblemswithyourworkorotherregulardailyactivitiesasaresultofyourphysicalhealthCutdowntheamountoftimeyouspentonworkorotheractivitiesYesNoAccomplishedlessthanyouwouldlikeYesNoWerelimitedinthekindofworkorotheractivitiesYesNoHaddifficultyperformingtheworkorotheractivities(forexample,ittookextraeffort)YesNoEMOTIONALHEALTHPROBLEMS:Duringthepast4weeks,haveyouhadanyofthefollowingproblemswithyourworkorotherregulardailyactivitiesasaresultofanyemotionalproblems(suchasfeelingdepressedoranxious)CutdowntheamountoftimeyouspentonworkorotheractivitiesYesNoAccomplishedlessthanyouwouldlikeYesNoDidn'tdoworkorotheractivitiesascarefullyasusualYesNoSOCIALACTIVITIES:Emotionalproblemsinterferedwithyournormalsocialactivitieswithfamily,friends,neighbors,orgroupsNotatallSlightlyModeratelySevereVerySeverePAIN:Howmuchbodilypainhaveyouhadduringthepast4weeksNoneVeryMildMildModerateSevereVerySevereDuringthepast4weeks,howmuchdidpaininterferewithyournormalwork(includingbothworkoutsidethehomeandhousework)NotatallAlittlebitModeratelyQuiteabitExtremelyENERGYANDEMOTIONS:Thesequestionsareabouthowyoufeelandhowthingshavebeenwithyouduringthelast4weeks.
Foreachquestion,pleasegivetheanswerthatcomesclosesttothewayyouhavebeenfeeling.
DidyoufeelfullofpepAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoubeenaverynervouspersonAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoufeltsodowninthedumpsthatnothingcouldcheeryouupAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoufeltcalmandpeacefulAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeDidyouhavealotofenergyAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoufeltdownheartedandblueAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeDidyoufeelwornoutAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoubeenahappypersonAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeDidyoufeeltiredAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeSOCIALACTIVITIES:Duringthepast4weeks,howmuchofthetimehasyourphysicalhealthoremotionalproblemsinterferedwithyoursocialactivities(likevisitingwithfriends,relatives,etc.
)AllofthetimeMostofthetimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeGENERALHEALTH:HowtrueorfalseiseachofthefollowingstatementsforyouIseemtogetsickalittleeasierthanotherpeopleDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalseIamashealthyasanybodyIknowDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalseIexpectmyhealthtogetworseDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalseMyhealthisexcellentDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalse
Dr:Date:ID#Age:Gender:M/FPleaseanswerthe36questionsoftheHealthSurveycompletely,honestly,andwithoutinterruptions.
GENERALHEALTH:Ingeneral,wouldyousayyourhealthis:ExcellentVeryGoodGoodFairPoorComparedtooneyearago,howwouldyourateyourhealthingeneralnowMuchbetternowthanoneyearagoSomewhatbetternowthanoneyearagoAboutthesameSomewhatworsenowthanoneyearagoMuchworsethanoneyearagoLIMITATIONSOFACTIVITIES:Thefollowingitemsareaboutactivitiesyoumightdoduringatypicalday.
DoesyourhealthnowlimityouintheseactivitiesIfso,howmuchVigorousactivities,suchasrunning,liftingheavyobjects,participatinginstrenuoussports.
Yes,LimitedalotYes,LimitedaLittleNo,NotLimitedatallModerateactivities,suchasmovingatable,pushingavacuumcleaner,bowling,orplayinggolfYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallLiftingorcarryinggroceriesYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallClimbingseveralflightsofstairsYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallClimbingoneflightofstairsYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallBending,kneeling,orstoopingYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallWalkingmorethanamileYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallWalkingseveralblocksYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallWalkingoneblockYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallBathingordressingyourselfYes,LimitedaLotYes,LimitedaLittleNo,NotLimitedatallPHYSICALHEALTHPROBLEMS:Duringthepast4weeks,haveyouhadanyofthefollowingproblemswithyourworkorotherregulardailyactivitiesasaresultofyourphysicalhealthCutdowntheamountoftimeyouspentonworkorotheractivitiesYesNoAccomplishedlessthanyouwouldlikeYesNoWerelimitedinthekindofworkorotheractivitiesYesNoHaddifficultyperformingtheworkorotheractivities(forexample,ittookextraeffort)YesNoEMOTIONALHEALTHPROBLEMS:Duringthepast4weeks,haveyouhadanyofthefollowingproblemswithyourworkorotherregulardailyactivitiesasaresultofanyemotionalproblems(suchasfeelingdepressedoranxious)CutdowntheamountoftimeyouspentonworkorotheractivitiesYesNoAccomplishedlessthanyouwouldlikeYesNoDidn'tdoworkorotheractivitiesascarefullyasusualYesNoSOCIALACTIVITIES:Emotionalproblemsinterferedwithyournormalsocialactivitieswithfamily,friends,neighbors,orgroupsNotatallSlightlyModeratelySevereVerySeverePAIN:Howmuchbodilypainhaveyouhadduringthepast4weeksNoneVeryMildMildModerateSevereVerySevereDuringthepast4weeks,howmuchdidpaininterferewithyournormalwork(includingbothworkoutsidethehomeandhousework)NotatallAlittlebitModeratelyQuiteabitExtremelyENERGYANDEMOTIONS:Thesequestionsareabouthowyoufeelandhowthingshavebeenwithyouduringthelast4weeks.
Foreachquestion,pleasegivetheanswerthatcomesclosesttothewayyouhavebeenfeeling.
DidyoufeelfullofpepAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoubeenaverynervouspersonAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoufeltsodowninthedumpsthatnothingcouldcheeryouupAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoufeltcalmandpeacefulAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeDidyouhavealotofenergyAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoufeltdownheartedandblueAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeDidyoufeelwornoutAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeHaveyoubeenahappypersonAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeDidyoufeeltiredAllofthetimeMostofthetimeAgoodBitoftheTimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeSOCIALACTIVITIES:Duringthepast4weeks,howmuchofthetimehasyourphysicalhealthoremotionalproblemsinterferedwithyoursocialactivities(likevisitingwithfriends,relatives,etc.
)AllofthetimeMostofthetimeSomeofthetimeAlittlebitofthetimeNoneoftheTimeGENERALHEALTH:HowtrueorfalseiseachofthefollowingstatementsforyouIseemtogetsickalittleeasierthanotherpeopleDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalseIamashealthyasanybodyIknowDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalseIexpectmyhealthtogetworseDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalseMyhealthisexcellentDefinitelytrueMostlytrueDon'tknowMostlyfalseDefinitelyfalse
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