Form 004_Sickle Cell_Ad 004_Sickle Cell_Ad 004_Sickle Cell_Adult Health Survey

OMB Number: xxxx-xxxx

Expiration Date:

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0915-xxxx.  Public reporting burden for this collection of information is estimated to average 30 minutes per respondent annually, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland, 20857.

Your Health and Well-Being

This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Thank you for completing this survey!

For each of the following questions, please mark an in the one box that best describes your answer.

1. In general, would you say your health is:

Excellent	Very good	Good	Fair	Poor
				
1	2	3	4	5

2. Compared to one year ago, how would you rate your health in general now?

Much better now than one year ago	Somewhat better now than one year ago	About the same as one year ago	Somewhat worse now than one year ago	Much worse now than one year ago
				
1	2	3	4	5

	Yes, limited a lot	Yes, limited a little	No, not limited at all
			
a Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports 1 2 3
b Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf 1 2 3
c Lifting or carrying groceries 1 2 3
d Climbing several flights of stairs 1 2 3
e Climbing one flight of stairs 1 2 3
f Bending, kneeling, or stooping 1 2 3
g Walking more than a mile 1 2 3
h Walking several hundred yards 1 2 3
i Walking one hundred yards 1 2 3
j Bathing or dressing yourself 1 2 3

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

4. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

	All of the time	Most of the time	Some of the time	A little of the time	None of the time
					
a Cut down on the amount of time you spent on work or other activities 1 2 3 4 5
b Accomplished less than you would like 1 2 3 4 5
c Were limited in the kind of work or other activities 1 2 3 4 5
d Had difficulty performing the work or other activities (for example, it took extra effort) 1 2 3 4 5

5. During the past 4 weeks, how much of the time 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)?

	All of the time	Most of the time	Some of the time	A little of the time	None of the time
					
a Cut down on the amount of time you spent on work or other activities 1 2 3 4 5
b Accomplished less than you would like 1 2 3 4 5
c Did work or other activities less carefully than usual 1 2 3 4 5

6. 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?

Not at all	Slightly	Moderately	Quite a bit	Extremely
				
1	2	3	4	5

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

None	Very mild	Mild	Moderate	Severe	Very severe
					
1	2	3	4	5	6

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

Not at all	A little bit	Moderately	Quite a bit	Extremely
				
1	2	3	4	5

9. 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…

	All of the time	Most of the time	Some of the time	A little of the time	None of the time
					
a Did you feel full of life? 1 2 3 4 5
b Have you been very nervous? 1 2 3 4 5
c Have you felt so down in the dumps that nothing could cheer you up? 1 2 3 4 5
d Have you felt calm and peaceful? 1 2 3 4 5
e Did you have a lot of energy? 1 2 3 4 5
f Have you felt downhearted and depressed? 1 2 3 4 5
g Did you feel worn out? 1 2 3 4 5
h Have you been happy? 1 2 3 4 5
i Did you feel tired? 1 2 3 4 5

10. 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.)?

All of the time	Most of the time	Some of the time	A little of the time	None of the time
				
1	2	3	4	5

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

	Definitely true	Mostly true	Don’t know	Mostly false	Definitely false
					
a I seem to get sick a little easier than other people 1 2 3 4 5
b I am as healthy as anybody I know 1 2 3 4 5
c I expect my health to get worse 1 2 3 4 5
d My health is excellent 1 2 3 4 5

Thank you for completing these questions!

SF-36v2^® Health Survey  1992, 2000 Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved.

SF-36^® is a registered trademark of Medical Outcomes Trust.

(SF-36v2^® Health Survey Standard, United States (English))