Form 2 VR_English_Self

Self-Administered
OMB ###-####
Administrative use only:
Local Identifier

Study ID: _____________________

Navigator: ________________________
Date: ________________________

THE VETERANS RAND 12-ITEM HEALTH SURVEY (VR-12)
The following questions ask for your views about your health—how you feel and how
well you are able to do your usual activities. All kinds of people across the country are
being asked these same questions. Their answers and yours will help to improve health
care for everyone. There are no right or wrong answers; please choose the answer that
best fits your life right now.
Answer each question by marking an ‘X’ next to the best response. For example:
What is your gender?
 Male
 Female

Q1.

In general, would you say your health is:






Q2.

Excellent
Very good
Good
Fair
Poor

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?
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or
playing golf?
 Yes, limited a lot
 Yes, limited a little
 No, not limited at all
b. Climbing several flights of stairs?
 Yes, limited a lot
 Yes, limited a little
 No, not limited at all

Public reporting burden for this collection of information is estimated to average 7 minutes per response. This time includes the
length of time allotted for the survey questions. 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. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Address,
ATTN; PRA (XXX-XXXX). Do not return the completed form to this address.
Rev 19-Sep-2011

Entered: __ __ / __ __ / __ __ By: _______

Self-Administered

Q3.

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?
a. Accomplished less than you would like.






No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time

b. Were limited in the kind of work or other activities.






Q4.

No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time

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)?
a. Accomplished less than you would like.






No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time

b. Didn’t do work or other activities as carefully as usual.






No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
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Self-Administered

Q5.

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

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.
Q6a.

How much of the time during the past 4 weeks:
Have you felt calm and peaceful?







Q6b.

All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time

How much of the time during the past 4 weeks:
Did you have a lot of energy?







Q6c.

All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time

How much of the time during the past 4 weeks:
Have you felt downhearted and blue?







All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
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Self-Administered

Q7.

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

Now, we’d like to ask you some questions about how your health may have changed.
Q8.

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

Q9.

Much better
Slightly better
About the same
Slightly worse
Much worse

Compared to one year ago, how would you rate your emotional problems (such as
feeling anxious, depressed or irritable) now?






Much better
Slightly better
About the same
Slightly worse
Much worse

Your answers are important!
Thank you for completing this questionnaire!

The items in this questionnaire were obtained from the Medicare Health Outcomes Survey (HOS) with the express permission of
NCQA and the Centers for Medicare & Medicaid Services (CMS). However, this survey is not being used as part of the Medicare
HOS program and is not recognized as such by NCQA or CMS.
© 2010 by the National Committee for Quality Assurance (NCQA). This survey instrument may not be reproduced or transmitted in
any form, electronic or mechanical, without the express written permission of NCQA. All rights reserved.
Items 1-9: The VR-12 Health Survey item content was developed and modified from a 36-item health survey.
This survey was developed at RAND as part of the Medical Outcomes Study.
It was developed with support from the US Department of Veterans Affairs.
Permission received March 2011
®

HEDIS 2011 © 2011 by NCQA. All rights reserved.

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