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.
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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) 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?
B) 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)?
C) During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
D) 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.
E) We’d like to ask you some questions about how your health may have changed.