The SF-6D Questionnaire version 12-1

The following item is about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

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

Were limited in the kind of work or other activities
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)?

Accomplished less than you would like
1[] Yes
2[] No

During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
1[] Not at all
2[] A little bit
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:

Did you have a lot of energy?
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

Have you felt downhearted and blue?
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

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.)?
1[] All of the time
2[] Most of the time
3[] Some of the time
4[] A little of the time
5[] None of the time

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