Home Monitoring for Early Detection of Chronic Disease Exacerbation (COPD)

Home Monitoring for Early Detection of
Chronic Disease Exacerbation.
OMB No. 2900-0770

Estimated Burden: 12.5 minutes
Expiration Date: 9/30/2020

The Paperwork Reduction Act of 1995: This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you
are not required to respond to, a collection of information unless it displays a valid OMB number. We
anticipate that the time expended by all individuals who complete this survey will average 12.5
minutes. This includes the time it will take to follow instructions, gather the necessary facts and
respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA
services as well as customer expectations and desires. The results of this telephone/mail survey will
lead to improvements in the quality of service delivery by helping to achieve improved services.
Participation in this survey is voluntary and failure to respond will have no impact on benefits to which
you may be entitled.

1

SF-36 QUESTIONNAIRE
( 1992 -- Medical Outcomes Trust)

Patient Name: ______________________________

Date: _____________________

1. In general, would you say your health is: (circle one)
Excellent

Very good

Good

Fair

Poor

2. Compared to one year ago, how would you rate your health in general now? (circle one)
Much better now than one year ago.
Somewhat better now than one year ago.
About the same as one year ago.
Somewhat worse than one year ago.
Much worse than one year ago.

3. 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? (Mark each answer with an X)
ACTIVITIES
a. Vigorous activities, such as running, lifting heavy objects, participating in
strenuous sports
b. Moderate activities, such as moving a table, pushing a vacuum cleaner,
bowling, or playing golf
c. Lifting or carrying groceries
d. Climbing several flights of stairs
e. Climbing one flight of stairs
f. Bending, kneeling or stooping
g. Walking more than a mile
h. Walking several blocks
i. Walking one block
j. Bathing or dressing yourself

Yes,
Limited
A Lot

Yes,
Limited
A Little

No, Not
Limited
At All

4. 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? (Mark each answer with an X)
YES

NO

a. Cut down on the amount of time you spent on work or other activites
b. Accomplished less than you would like
c. Were limited in the kind of work or other activities
d. Had difficulty performing the work or other activities (for example, it took extra effort)

5. 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)? (Mark each answer with an X)
YES

NO

a. Cut down the amount of time you spent on work or other activities
b. Accomplished less than you would like
c. DidnÕt do work or other activities as carefully as usual

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?
(circle one)
Not at all

Slightly

Moderately

Quite a bit

Extremely

7. How much bodily pain have you had during the past 4 weeks? (circle one)
None

Very mild

Mild

Moderate

Severe

Very severe

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

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 Ð (Mark each answer with an X)
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

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?

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.)?
(circle one)
All of the time

Most of the time

Some of the time

A little of the time

None of the time

11. How TRUE or FALSE is each of the following statements for you?
Definitely
True
a. I seem to get sick a little easier than other
people
b. I am as healthy as anybody I know
c. I expect my health to get worse
d. My health is excellent

Mostly
True

DonÕt
Know

Mostly
False

Definitely
False