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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, how much did pain interfere with your normal work (including both work outside the home and housework)?
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?
Below are a number of statements that people often use to describe themselves. Please read each statement and then circle the appropriate number next to that statement to indicate your answer. There are no right or wrong answers. Your own impression is the only thing thing that matters.
Perception. For the following questions, please circle the number that best corresponds to your views.
How much does your illness affect you emotionally? (e.g. does it make you angry, scared, upset or depressed?
Anxiety and depression. The following questions are about how you feel right now. Please choose the answer that best describes your current feeling. Do not think too long about your answer. These statements are about your personal impression. There are no wrong answers: it is opinion based.
