YesNo
Activity Restriction
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
Lifting or carrying groceries
Climbing several flights of stairs
Climbing one flight of stairs
Bending, kneeling, or stooping
Walking more than a mile
Walking several blocks
Walking one block
Bathing or dressing yourself
yes Problems
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? Cut down the amount of time you spent on work or other activities
Accomplished less than you would like
Were limited in the kind of work or other activities
Had difficulty performing the work or other activities (for example, it took extra effort)
yes Problems
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)? Cut down the amount of time you spent on work or other activities
Accomplished less than you would like
Didn't do work or other activities as carefully as usual
Question Duration
a) Did you feel full of pep?
b) Have you been a very nervous person?
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 blue?
g) Did you feel worn out?
h) Have you been a happy person?
i) Did you feel tired?
Expression Accuracy
I seem to get sick a little easier than other people
I am as healthy as anybody I know
I expect my health to get worse
My health is excellent