SF-36健康自测量表

1、Terms and Conditions for Using the 36-Item Short Form Survey (SF-36)/health/surveys_tools/mos/36-item-short-form.html一，使用说明RAND hereby grants permission to use RAND 36-Item Short Form Health Survey in accordance with the following conditions, which shall be assumed by all to have b

2、een agreed to as a consequence of accepting and using this document:1. Changes to the Health Survey may be made without the written permission of RAND. However, all such changes shall be clearly identified as having been made by the recipient.2. The user of this Health Survey accepts full responsibi

3、lity, and agrees to indemnify and hold RAND harmless, for the accuracy of any translations of the Health Survey into another language and for any errors, omissions, misinterpretations, or consequences thereof.3. The user of this Health Survey accepts full responsibility, and agrees to indemnify and

4、hold RAND harmless, for any consequences resulting from the use of the Health Survey.4. The user of the 36-Item Health Survey will provide a credit line when printing and distributing this document acknowledging that it was developed at RAND as part of the Medical Outcomes Study.5. No further writte

5、n permission is needed for use of this Health Surv二，英文量表/health/surveys_tools/mos/36-item-short-form/survey-instrument.htmlRAND 36-Item Health Survey 1.0 Questionnaire ItemsSF-36 Resources· Terms and Conditions for Using the SF-36· MOS 36-Item Short Form Survey Instrument

6、 (SF-36)(English PDF)· MOS 36-Item Short Form Survey Instrument (SF-36)(Arabic PDF)· Scoring Instructions for MOS 36-Item Short Form Survey Instrument (SF-36)Choose one option for each questionnaire item.1. In general, would you say your health is: 1 - Excellent 2 - Very good

7、0;3 - Good 4 - Fair 5 - Poor2. Compared to one year ago, how would you rate your health in general now? 1 - Much better now than one year ago 2 - Somewhat better now than one year ago 3 - About the same 4 - Somewhat worse now than one year ago 5 - Much wo

8、rse now than one year agoThe 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? Yes, limited a lotYes, limited a littleNo, not limited at all3. Vigorous activities, such as running, lifting

9、heavy objects, participating in strenuous sports 1 2 34. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf 1 2 35. Lifting or carrying groceries 1 2 36. Climbing several flights of stairs 1

10、 2 37. Climbing one flight of stairs 1 2 38. Bending, kneeling, or stooping 1 2 39. Walking more than a mile 1 2 310. Walking several blocks 1 2 311. Walking one block 1 2 312. Bathing or dr

11、essing yourself 1 2 3During 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? YesNo13. Cut down the amount of time you spent on work or other activities 1

12、0;214. Accomplished less than you would like 1 215. Were limited in the kind of work or other activities 1 216. Had difficulty performing the work or other activities (for example, it took extra effort) 1 2During the past 4 weeks, have

13、 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)? YesNo17. Cut down the amount of time you spent on work or other activities 1 218. Accomplished

14、 less than you would like 1 219. Didn't do work or other activities as carefully as usual 1 220. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neig

15、hbors, or groups? 1 - Not at all 2 - Slightly 3 - Moderately 4 - Quite a bit 5 - Extremely21. How much bodily pain have you had during the past 4 weeks? 1 - None 2 - Very mild 3 - Mild 4 - Moderate 5 - Severe 6 - Very severe22. Du

16、ring the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? 1 - Not at all 2 - A little bit 3 - Moderately 4 - Quite a bit 5 - ExtremelyThese questions are about how you feel and how things hav

17、e 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 timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the

18、 time23. Did you feel full of pep? 1 2 3 4 5 624. Have you been a very nervous person? 1 2 3 4 5 625. Have you felt so down in the dumps that nothing could cheer you up? 1 2 3 4 5 626. Have you felt calm and pe

19、aceful? 1 2 3 4 5 627. Did you have a lot of energy? 1 2 3 4 5 628. Have you felt downhearted and blue? 1 2 3 4 5 629. Did you feel worn out? 1 2 3 4 5 630. Have you been a happy p

20、erson? 1 2 3 4 5 631. Did you feel tired? 1 2 3 4 5 632. 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, relativ

21、es, etc.)? 1 - All of the time 2 - Most of the time 3 - Some of the time 4 - A little of the time 5 - None of the timeHow TRUE or FALSE is each of the following statements for you. Definitely trueMostly trueDon't knowMostly falseDefinitely false33. I seem

22、to get sick a little easier than other people 1 2 3 4 534. I am as healthy as anybody I know 1 2 3 4 535. I expect my health to get worse 1 2 3 4 536. My health is excellent 1 2 3 4 5健康状况调查问卷（SF36）及其使

23、用说明健康状况调查问卷（SF36）以下问题是询问您对自己健康状况的看法，您自己觉得做日常活动的能力怎么样。如果您不知如何回答是好，就请您尽量给出最好的答案，并在本问卷最后的空白处写上你的注释与评论。请一个答案1.总体来讲，您的健康状况是： 非常好很好好一般差2跟一年前相比，您觉得您现在的健康状况是：比一年前好多了比一年前好一些跟一年前差不多比一年前差一些比一年前差多了健康和日常活动3以下这些问题都与日常活动有关。请您想一想，您的健康状况是否限制了这些活动？如果有限制，程度如何？请在每一行一个答案有限制 有限制 毫无限制很大 有些限制 限制（l）重体力活动，如：跑步、举重物、参加剧烈运动等 （2

24、）适度的活动，如：移动一张桌子、扫地、打太极拳、做简单体操等 （3）手提日用品，如买菜、购物等 （4）上几层楼梯 （5）上一层楼梯 （6）弯腰、曲膝、下蹲 （7）步行 1600m以上的路程 （8）步行800m的路程 （9）步行 100m的路程 （10）自己洗澡、穿衣 4在过去四个星期里，您的工作和日常活动有无因为身体健康的原因而出现以下这些问题？对每条问题请回答“是”或“不是” 是 不是（1）减少了工作或活动的时间 （2）本来想要做的事情只能完成一部分 （3）想要干的工作和活动的种类受到限制 （4）完成工作或其他活动困难增多（比如需要额外的努力） 5在过去四个星期里，您的工作和日常活动有无因为

25、情绪的原因（如压抑或者忧虑），而出现以下问题？对每条问题请回答“是”或“不是” 是 不是（l）减少了工作或活动的时间（2）本来想要做的事情只能完成一部分（3）干事情不如平时仔细 6在过去的四个星期里，你的健康或情绪不好在多大程度上影响了您与家人、朋友、邻居或集体的正常社会交往？请一个答案：安全没影响有一点影响中等影响影响很大影响非常大7过去四个星期里，您有身体疼痛吗？完全没有疼痛稍微有一点疼痛有一点疼痛中等疼痛严重疼痛很严重疼痛8.过去四个星期里，身体上的疼痛影响你的工作和家务事吗？完全没有影响有一点影响中等影响影响很大影响非常大您的感觉9以下这些问题有关过去一个月里您自己的感觉，对每一条问题

26、所说的事情，你的情况是什么样的？请圈出最接近您的情况的那个答案。请在每一条问题后出一个答案持续的时间所有的时间大部分时间比较多时间一部分时间一小部分时间没有这种感觉（l）您觉得生活充实（2）您是一个敏感的人（3）您情绪非常不好，什么事都不能使您高兴（4）您心里很平静（5）您做事精力充沛（6）你的情绪低落（7）你觉得精疲力尽（8）您是个快乐的人（9）您感觉厌烦（10）不健康影响了您的社会活动（如走亲访友等）总体健康情况10请看下列每一条问题，哪一种答案最符合您的情况？请在每一条问题后一个答案绝对正确大部分正确不能肯定大部分错误绝对错误（l）我好像比别人容易生病（2）我跟周围人一样健康（3）我认为我的健康状况在变坏（4）我的健康状况非常好 如果您有注释或评论，请写在下面：非常感谢您的合作！请按要求将这份表填好后交还给我们 评分原则： （l）该量表为MOS-SF36生存质量