1. Do you have any trouble doing strenuous activities like|
carrying a heavy shopping bag or a suitcase?
|2. Do you have any trouble taking a long walk?||7||4||5||5|
|3. Do you have any trouble taking a short walk?||14||3||2||2|
|4. Do you need to stay in bed or a chair during the day?||5||6||7||3|
5. Do you need help with eating, dressing, washing yourself|
or using the toilet?
|During the past week:|
6. Were you limited in doing either your work or other daily|
7. Were you limited in pursuing your hobbies or other|
leisure time activities?
|8. Were you short of breath?||14||1||6||0|
|9. Have you had pain?||6||5||8||2|
|10. Did you need to rest?||1||9||8||3|
|11. Have you had trouble sleeping?||11||5||3||2|
|12. Have you felt weak?||5||8||5||3|
|13. Have you lacked appetite?||10||6||3||2|
|14. Have you felt nauseated?||15||4||2||0|
|15. Have you vomited?||17||3||0||0|
|16. Have you been constipated?||8||8||2||3|
|17. Have you had diarrhea?||14||4||2||1|
|18. Were you tired?||3||9||6||3|
|19. Did pain interfere with your daily activities?||7||5||5||4|
20. Have you had difficulty in concentrating on things, like|
reading a newspaper or watching television?
|21. Did you feel tense?||14||5||1||1|
|22. Did you worry?||11||8||1||1|
|23. Did you feel irritable?||13||5||3||0|
|24. Did you feel depressed?||11||7||2||0|
|25. Have you had difficulty remembering things?||13||5||3||0|
26. Has your physical condition or medical treatment|
interfered with your family life?
27. Has your physical condition or medical treatment|
interfered with your social activities?
28. Has your physical condition or medical treatment|
caused you financial difficulties?
29. How would you rate your overall|
health during the past week? (n)
30. How would you rate your overall|
quality of life during the past week? (n)