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We are interested in your current work situation. Will you please check the box with the answer that best applies to you? It is possible to give more than one answer.
Instruction: The following questions are about your views regarding your health. In this manner we are able to record how you feel and how well you are able to do your usual activities. Please answer each question by checking the box in the indicated manner. If you are not sure how to answer a...
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?
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?
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)?
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?
During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
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:
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.)?
Below you see a list of chronic conditions and diseases. Please indicate for each condition or disease whether you have it now or have had it in the past 12 months. Please answer this for each condition or disease.
We would like to know how cancer affects your life. Please answer the following questions. Choose the answer that best applies to you. There are no right or wrong answers: Your own impression is all that matters.
