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RAND 36-Item Health Survey Questionnaire: (Version 1.0)

This document contains a 36-item questionnaire that assesses health status across several domains of physical, emotional, and social functioning. It includes questions about general health, limitations in daily activities due to physical health problems, pain interference, energy levels, social activities, and overall health perceptions. The questionnaire was developed by RAND to measure health outcomes in clinical research studies.

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157 views

RAND 36-Item Health Survey Questionnaire: (Version 1.0)

This document contains a 36-item questionnaire that assesses health status across several domains of physical, emotional, and social functioning. It includes questions about general health, limitations in daily activities due to physical health problems, pain interference, energy levels, social activities, and overall health perceptions. The questionnaire was developed by RAND to measure health outcomes in clinical research studies.

Uploaded by

J Korisne knjige
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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RAND 36-Item Health Survey Questionnaire (Version 1.

0)

1. In general, would you


say
your health is:

Excellent 1

Very good 2

Good 3

Fair 4

Poor 5

2. Compared to one year ago,


how would your rate your health in general
now?

Much better now than one year ago 1

Somewhat better now than one year ago 2

About the same 3

Somewhat worse now than one year ago 4

Much worse now than one year ago 5

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?

(Circle One Number on Each Line)

Yes, Yes, No, Not


Limited a Limited a limited at
Lot Little All

3. Vigorous activities, such as running, [1] [2] [3]


lifting heavy objects, participating in
strenuous sports

4. Moderate activities, such as moving [1] [2] [3]


a table, pushing a vacuum cleaner,
bowling, or playing golf
5. Lifting or carrying groceries [1] [2] [3]

6. Climbing several flights of stairs [1] [2] [3]

7. Climbing one flight of stairs [1] [2] [3]

8. Bending, kneeling, or stooping [1] [2] [3]

9. Walking more than a mile [1] [2] [3]

10. Walking several blocks [1] [2] [3]

11. Walking one block [1] [2] [3]

12. Bathing or dressing yourself [1] [2] [3]

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?

(Circle One Number on Each Line)

Yes No

13. Cut down the amount of time you spent on work or other activities 1 2

14. Accomplished less than you would like 1 2

15. Were limited in the kind of work or other activities 1 2

16. Had difficulty performing the work or other activities (for example, 1 2
it took extra effort)

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)?

(Circle One Number on Each Line)


Yes No

17. Cut down the amount of time you spent on work or other 1 2
activities

18. Accomplished less than you would like 1 2

19. Didn't do work or other activities as carefully as usual 1 2

20. 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?

(Circle One Number)

Not at all 1

Slightly 2

Moderately 3

Quite a bit 4

Extremely 5

21. How much bodily pain have you had during the past 4 weeks?

(Circle One Number)

None 1

Very mild 2

Mild 3

Moderate 4

Severe 5

Very severe 6

22. During the past 4 weeks, how much did pain interfere with your normal work
(including both work outside the home and housework)?

(Circle One Number)

Not at all 1

A little bit 2
Moderately 3

Quite a bit 4

Extremely 5

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 . . .

(Circle One Number on Each Line)

A Good
All of Most Bit of Some A Little None
the of the the of the of the of the
Time Time Time Time Time Time

23. Did you feel full 1 2 3 4 5 6


of pep?

24. Have you been a 1 2 3 4 5 6


very nervous person?

25. Have you felt so 1 2 3 4 5 6


down in the dumps
that nothing could
cheer you up?

26. Have you felt 1 2 3 4 5 6


calm and peaceful?

27. Did you have a 1 2 3 4 5 6


lot of energy?

28. Have you felt 1 2 3 4 5 6


downhearted and
blue?

29. Did you feel worn 1 2 3 4 5 6


out?

30. Have you been a 1 2 3 4 5 6


happy person?

31. Did you feel 1 2 3 4 5 6


tired?
32. 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.)?

(Circle One Number)

All of the time 1

Most of the time 2

Some of the time 3

A little of the time 4

None of the time 5

How TRUE or FALSE is each of the following statements for you.

(Circle One Number on Each Line)

Definitely Mostly Don't Mostly Definitely


True True Know False False

33. I seem to get sick 1 2 3 >4 5


a little easier than
other people

34. I am as healthy as 1 2 3 4 5
anybody I know

35. I expect my health 1 2 3 4 5


to get worse

36. My health is 1 >2 3 4 5


excellent

This questionnaire was developed at RAND as a part of the Medical


Outcomes Study and is provided here with permission from RAND.

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